Newborn PrepU 240

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?

Do nothing — acrocyanosis is normal in the neonate. Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. Activating the code emergency response system, taking the neonate's temperature, and notifying the physician that a cardiac consult is needed are inappropriate actions.

A nurse is conducting a physical examination on a neonate. Which pulse point should the nurse check if a possible coarctation of the aorta is suspected?

femoral With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. These findings occur because of the narrowing of the aortic arch.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?

helps lungs remain expanded after the initiation of breathing improving oxygenation Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract.

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find

irritability and poor sucking. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in neonates with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish tinge to the hands and feet) is normal on the first day after birth.

A mother who gave birth some three hours ago asked the nurse why her baby is so difficult to keep awake. The nurse informs the mother that this behavior indicates

normal progression into the sleep cycle. Typically, it's difficult to awaken any neonate 3 hours after birth. This finding suggests normal progression into the sleep cycle. During this period, the neonate shows minimal response to external stimuli. Hypoglycemia is characterized by irregular respirations, apnea, and tremors. Periods of neonatal reactivity are characterized by alertness and attentiveness.

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis. Projectile vomiting is a classic symptom of pyloric stenosis, which typically occurs within the first weeks of life. Upper GI X-rays confirm this diagnosis. Gastroschisis, diaphragmatic hernia, and imperforate anus would have been evident in the hours immediately after birth, and the reported symptoms don't characterize these conditions.

A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?

respiratory depression Magnesium sulfate crosses the placenta. Potential neonatal effects include respiratory depression, hypotonia, and bradycardia. The serum blood glucose is not affected by magnesium sulfate. The neonate would likely be floppy, not jittery.

A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from

the neonate's mother because she's considered an emancipated minor. Because the 16-year-old has given birth, she's considered an emancipated minor and may legally consent to the treatment. The neonate's grandparents have no legal authority to give consent for the neonate. The father doesn't have to consent to the treatment. The 16-year-old mother doesn't have to wait for a court order to declare her legal emancipation.

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?

"The vernix indicates a different gestational age than expected." Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older." The nurse should explain to the mother that the neonate might have acquired HIV in utero, but that a diagnosis can't be made until the neonate is older. Diagnosing AIDS in neonates is difficult because all neonates of women with HIV receive maternal antibodies and therefore initially test positive for HIV antibodies. Saying, "Don't worry. It's too soon to tell" minimizes the mother's concern and doesn't provide specific information. Saying that chances are the neonate will be okay could promote false hope. Stating that all neonates born to HIV-positive women are infected isn't true. Neonates of HIV-positive mothers have a 25% to 30% chance of developing HIV.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?

Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. The normal axillary temperature range for a neonate is 97.7 to 99.5°F (36.5 to 37.5°C). A temperature of 97.3°F (36.3°C) is slightly below normal. Because the neonate is full-term, it is safe to warm the neonate using conservative measures such as placing a cap on the head and trying skin-to-skin contact. There is no need to encourage feeding. Performing an assessment would require exposing the neonate and is not indicated. If this were an unstable or preterm neonate, an incubator may be recommended due to the underdeveloped thermoregulation in these neonates. Neonates with hypothermia experience bradycardia, which is defined as a heart rate less than 100 beats/minute.

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. The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

The parents of a young infant are exhausted and frustrated because their infant has colic and cries constantly. What intervention(s) should the nurse teach the parents to help console the infant? Select all that apply.

Place the infant in a swing. Carry the infant in a carrier strapped to you. Offer the infant a pacifier. Colic is defined as inconsolable crying that lasts 3 hours or more and for which there is no physical cause. The crying and fussiness is most prevalent in the evenings. Although a cause has never been identified some contributing factors include gastrointestinal issues, neurological immaturity, temperament, and the parenting styles. To help the infant stop crying the parents should take a step-wise approach. First determine that all the infant's needs have been met. Then, one step at a time, use things like a swing, a car ride, different pacifier, or carrying the infant in a carrier strapped to the body. The infant should not be overstimulated in the process. Feeding in an upright position will increase the amount of air swallowed, which can worsen gastrointestinal upset. The infant should be fed in a vertical position and the parents should use a curved bottle, which may further reduce the swallowing of air. The use of simethicone is not advised because the safety for infants has not been established.

Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do?

Rewarm the neonate gradually. A neonate with a temperature of 94.1°F(34.5°C) is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Bathing the baby will further cause the baby to lose heat. Hourly observation is not frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the healthcare provider of the problem as soon as it is identified.

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?

Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Parents have the legal right to decide whether their son is circumcised. The nurse and physician should always check the medical record for a signed informed consent form before beginning any procedure. It's unacceptable for the nurse to ask for consent after the procedure. Quickly completing the circumcision is also unacceptable because an informed consent form wasn't signed. Both the nurse and physician were negligent for not checking for a signed informed consent form.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate?

Urine output below 1 ml/hour Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed, not bulging, fontanels; excessive weight loss, not gain; decreased skin turgor; dry mucous membranes; and urine specific gravity above, not below, 1.012.

A nurse is providing care to a neonate. Place the following steps in the order that the nurse would implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.

Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and gently pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents?

a neonate who's in good condition An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

The nurse scores the newborn an Apgar score of 8 at 1 minute of life. What findings would the nurse assess for the neonate to achieve a score of 8?

heart rate over 100, respiratory rate 40, flexion, vigorous cry, blue extremities Five parameters are assessed with Apgar scoring. A: appearance (color), P: pulse (heart rate), G: grimace (reflex irritability), A: activity (muscle tone), R: respiratory (respiratory effort). An infant can be scored from 0 to 2 in any of these areas. Answer A scores an 8 (has only some flexion and acrocyanosis). Answer B scores a 5 (low heart rate, normal RR, limited resistance to extension, frown, pale). Answer C scores a 10 (normal in all 5 categories). Answer D scores a 3 (low heart rate, irregular respiratory effort, limp and flaccid, grimace, pale).

What site should the nurse use to obtain a blood sample to screen a neonate for phenylketonuria (PKU)?

heel The blood sample for routine screening for phenylketonuria, done after the neonate has been eating for 48 hours, is obtained from a heel stick. The lateral heel is the best site because it prevents damage to the posterior tibial nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel.The radial artery is an inappropriate site to obtain the blood sample because of the risk for severe trauma.The scalp vein is used for intravenous infusions, not to obtain a blood sample for PKU.The brachial artery is not an appropriate site for obtaining a PKU blood sample because the artery is too small and severe trauma may result.

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy?

recommending the use of analgesia for circumcision Recommending the use of analgesia is an example of advocacy for the neonate. Ensuring that the neonate has been NPO for at least 6 hours before the procedure, monitoring for excessive bleeding after the procedure, and returning the neonate to his mother for comfort and bonding are examples of providing safe care, not of advocacy.

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

temperature instability Neonatal sepsis is oftentimes difficult to diagnose because many of the symptoms are nonspecific in the beginning. Sometimes the nurse uses intuition and experience and describes the baby as "not looking right." One of the first signs of sepsis is that the infant cannot maintain temperature and becomes hypothermic. Other symptoms include pallor, poor feeding, irritability, apnea and bradycardia, respiratory distress, and abdominal distention. Hypotension may be seen in neonatal sepsis, but it is a late sign, not an early sign. In infants and children, the blood pressure is the last vital sign to exhibit a change. If hypotension has occurred, the infant is already very ill. Gastric retention and blood in the stool are signs of necrotizing enterocolitis and should be monitored closely in infants who are at risk.

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).