Newborn at Risk

What is the normal range for potassium?

3.5 to 4.5

Which assessment finding would lead a nurse to suspect fluid overload in a preterm neonate? Select all that apply Urine output below 1 ml/hour Increased skin turgor Excessive weight loss Excessive weight gain Urine specific gravity below 1.012 Bulging fontanels Decreased skin turgor Urine specific gravity above 1.012

Bulging fontanels Excessive weight gain Increased skin turgor Urine specific gravity below 1.012

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of having meconium-stained amniotic fluid and developing meconium aspiration syndrome)? The neonate born by cesarean section The neonate born at 42 weeks The neonate experiencing apneic episodes The preterm infant born at 36 weeks

Correct response: The neonate born at 42 weeks

What are the signs and symptoms of Facial nerve paralysis? 1. lethargy, bulging fontanels, loss of moro reflex, and seizure activity 2. respiratory distress, grunting, nasal flaring, and cyanosis 3. no movement on one side of the face

Facial nerve paralysis no movement on one side of the face

Of glucose and insulin, which crossess the placenta and which does not?

Glucose crosses the placenta, but insulin does not

What conditions would the nurse expect to find initially in a preterm neonate suffering from cold stress?

Hyperactivity and twitching are signs of hypoglycemia.

Why is it important to ensure an infant peed before giving them potassium?

If an infant can't pee, then they can't get all the potassium out, so when you give them potassium they will not be able to pass out any extra and could get hyperpotassium which can make the heart beat all screwy.

What are the signs and symptoms of Intracranial hemorrhage? 1. lethargy, bulging fontanels, loss of moro reflex, and seizure activity 2. respiratory distress, grunting, nasal flaring, and cyanosis 3. no movement on one side of the face

Intracranial hemorrhage Lethargy, bulging fontanels, loss of moro reflex, and seizure activity

What are the signs and symptoms of Postnatal asphyxia? 1. lethargy, bulging fontanels, loss of moro reflex, and seizure activity 2. respiratory distress, grunting, nasal flaring, and cyanosis 3. no movement on one side of the face

Postnatal asphyxia respiratory distress, grunting, nasal flaring, and cyanosis

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of fluid retention in the lungs? The neonate born by cesarean section The neonate born at 42 weeks The neonate experiencing apneic episodes The preterm infant born at 36 weeks

The neonate born by cesarean section

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? 6. Lots of scalp hair 7. Dropped testicles 8. Thin, wasted appearance 9. Creases on soles of feet

The premature neonate characteristically exhibits a thin, wasted appearance.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? Select all that apply Urine output below 1 ml/hour Increased skin turgor Excessive weight loss Excessive weight gain Urine specific gravity below 1.012 Bulging fontanels Decreased skin turgor Urine specific gravity above 1.012

Urine output below 1 ml per hour Excessive weight loss Decreased skin turgor Urine specific gravity above 1.012

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age? 1. Firm cartilage to the edge of the ear pinna 2. fine, downy hair over the upper arms and back 3. Ability to bring elbows to midline with resistance past midline 4. Creases on the soles and heels

fine, downy hair over the upper arms and back Explanation: Lanugo (fine, downy hair) covers the entire body until about 20 weeks' gestation

A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which interventions? Select all that apply. Screen and isolate the infant for Hep B hepatitis B immune globulin at birth Inform the mom that breastfeeding will not be possible series of three hepatitis B vaccinations per recommended schedule standard/routine precautions for mother and infant

hepatitis B immune globulin at birth series of three hepatitis B vaccinations per recommended schedule standard/routine precautions for mother and infant

What type of baby is at greatest risk for RDS?

preterm because low surfactant.

A preterm neonate is having frequent blood draws for laboratory specimens. What is most important for the nurse to document about the blood draws?

• amount of blood drawn for each specimen

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in:

• an arched, side-lying position, avoiding flexion of the neck onto the chest.

A newborn diagnosed with phenylketonuria (PKU) is placed on a low-phenylalanine formula. The mother asks the nurse how long her infant will need to have dietary restriction. What response would be appropriate?

• "Most likely he will need to follow a low phenylalanine diet for the rest of his life." Explanation: PKU is the lack of the enzyme that breaks down phenylalanine. Like being lactose intolerant, it never gets better throughout the person's life because they just don't have the enzyme to process the phenylalanine.

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. What should the nurse should tell the mother?

• "Oxygen is drying to the mucous membranes unless it is humidified." Drying impedes the normal functioning of cilia in the respiratory tract and predisposes to mucous membrane irritation.

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy?

• "Phototherapy decreases the serum unconjugated bilirubin level." Explanation: The goal of phototherapy is to decrease the serum unconjugated bilirubin level

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which organ in the neonate?

• Brain (EF = Rh Incompatibility = less heme = inc bilirubin levels = kernicterus) Explanation: Rh incompatibility, or erythroblastosis fetalis, can cause kernicterus due to decreased heme molecules to carry the bilirubin.

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?

• Burp the infant at frequent intervals. Explanation: An infant with a cleft lip and palate typically swallows large amounts of air while being fed

The nurse plans the discharge of a newborn diagnosed with torticollis (wry neck). Which action should the nurse take?

• Coordinate outpatient physical therapy.

When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, the nurse should include which action as the priority when the parents visit the infant for the first time?

• Emphasize the infant's normal and positive features.

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. At what age does the nurse should tell the client to start modifying her child's diet?

• age 2 years Explanation: Infants and toddlers younger than age 2 should not be placed on a fat-restricted diet because cholesterol and other fatty acids are required for continued neural growth.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate?

• Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Explanation: Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it.

Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. What action would be most appropriate at this time?

• Give the infant a pacifier to suck on. Explanation: pyloric stenosis is when the lower part of the stomach that goes into the intestines isn't open.

A neonate was admitted to the pediatric unit with an unexpected congenital defect. What is the best way to involve the parents in the neonate's care?

• Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98° F (36.6° C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

• Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. Explanation: The concern with this infant is sepsis based on prolonged rupture of membranes before birth.

The charge nurse observes that a nurse caring for a very sick infant is making inappropriate remarks and acting bizarrely. What is the first action the charge nurse should take?

• Remove this nurse from the client assignment.

While caring for a neonate of a woman with diabetes soon after birth, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level, and it is 60 mg/dL (3.3 mmol/L), but the neonate continues to exhibit jitteriness and tremors. What should the nurse do first? 1. Begin a glucose IV based on a infant glucose level 2. Recheck the neonate's temperature 3. Request a prescription for a blood calcium level 4. Refeed the infant

• Request a prescription for a blood calcium level. Explanation: babys glucose is normal. Mom's with diabetes have high calcium usually. This means, the baby isn't secreting parathyroid in utero to stimulate calcium because mom is producing so much. Once the baby comes out, they'll have hypocalcemia, because they are used to mom's super high calcium environment.

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease?

• Signs of kernicterus Explanation: Neonates with an Rh and ABO incompatibility are likely to develop severe jaundice as a result of rising bilirubin.

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?

• Small size for gestational age Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus,

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?

• Symptoms of withdrawal include tremors, sleeplessness, and seizures.

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first?

• Verify that the infant has urinated. Explanation: Normal serum potassium levels are 3.5 to 4.5. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug.

The nurse determines that a newborn is experiencing hypoglycemia based on which findings? Select all that apply. • irregular respirations, tremors, and hypothermia • large for gestational age • a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour • family history of insulin-dependent diabetes

• a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour • irregular respirations, tremors, and hypothermia

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)? The neonate born by cesarean section The neonate born at 42 weeks The neonate experiencing apneic episodes The preterm infant born at 36 weeks

• a neonate born at 36 weeks' gestation Explanation: The preterm infant is at greatest risk for developing RDS

What should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply. • abdominal distension • Difficulty peeing • vomiting • Loose stool • meconium in the urine

• abdominal distension • vomiting • meconium in the urine Explanation: Anoectal malformations are when the toot shoot either isn't there at all or it communicates with another area like the vagina or balls.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which body position is appropriate for a preterm neonate?

• adduction and flexion of the extremities with gently rounded shoulders

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which complications?

• copious frothy mucus/excessive secretions • episodes of cyanosis • distended abdomen

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior? 1. Projectile vomiting 2. Poor rooting reflexes and sucking attempts 3. coughs, chokes, and becomes cyanotic 4. Falling asleep after taking little formula

• coughing, choking, and cyanosis that occur after several swallows of formula

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to

• enhance bonding by pointing out the neonate's features.

When performing an assessment on a one-day old newborn, which finding would be most suggestive of an imperforate anus?

• failure to pass a meconium stool because the neonate has no outlet to pass stool.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal?

• high-pitched cry Explanation: Manifestations of opiate withdrawal in the neonate, known as neonatal abstinence syndrome (NAS), include an increased central nervous system irritability, gastrointestinal symptoms, and metabolic, vasomotor, and respiratory disturbances.

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication?

• hypoglycemia Explanation: Neonates that are septic use glucose at an increased rate.

Which finding provides the most evidence that a fetus might have a gastrointestinal tract anomaly? 1. Meconium in the amniotic fluid 2. Low implantation of the placenta 3. Preeclampsia 4. Increased amniotic fluid amount

• increased amount of amniotic fluid Explanation: Amniotic fluid is mostly fetal urine.

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason?

• interrupted supply of maternal glucose and continued high neonatal insulin production Explanation: A high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin.

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication? 1. Postnatal asphyxia 2. Skull Fracture 3. Intracranial hemorrhage 4. Facial Nerve Paralysis

• intracranial hemorrhage Explanation: Other symptoms include lethargy, bulging fontanels, and seizure activity.

Which factor would the nurse explain as the factor placing the neonate at the greatest risk for respiratory distress syndrome (RDS)?

• neonate born preterm Explanation: Baby born before 35 weeks doesn't have developed lungs, so they don't have enough surfactant, so they get respiratory distress syndrome.

While caring for several preterm infants in the special care nursery, which action is most important for preventing nosocomial infections in these neonates?

• performing thorough handwashing before giving infant care Explanation: The number one cause of nosocomial infections in hospital units is not washing the hands.

A neonate born at 28 weeks' gestation has been receiving 80% to 100% oxygen via mechanical ventilation for the past 2 weeks and blood transfusions to treat anemia and has experienced severe apnea. The nurse caring for the neonate should anticipate which complication? 1. Transient tachypnea 2. Hyperbilirubinemia 3. Neonatal asphyxia 4. Retinopathy of prematurity

• retinopathy of prematurity

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication?

• retinopathy of prematurity Explanation: High levels of oxygen delivered to a preterm neonate can result in The immature blood vessels in the eye constricting/popping

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance?

• surfactant Explanation: RDS, previously called hyaline membrane disease, is a developmental condition involving a decrease in lung surfactant leading to improper expansion of the lung alveoli.

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which screening in the infant's plan of care?

• urine toxicology screening