Newborn Unit Test #2

A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is:

"Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the rectal area. Sometimes it migrates to the vaginal canal without reason. Do you have other questions regarding your baby's health?"

A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is:

"Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health."

A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions?

Feeding neonate every 2 to 3 hours

The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at:

48 to 72 hours It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may be heard initially, the sound disappears within 2 to 3 days when the ductus closes. If a murmur remains audible after the second day of life and intensifies to a "whoosh" sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.

Which of the following neonates is at highest risk for cold stress?

A 33 gestational week SGA (small for gestational age) neonate

A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the following stages of activity?

First period of reactivity The best stage for initiating breastfeeding is the first period of active, alert wakefulness that the infant displays immediately after birth, which may last from 30 minutes to 2 hours.

The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included?

Gather all supplies before beginning the bath.

The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?

Grunting

The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider?

Absent bowel sounds

A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result?

Circumcision site oozes blood.

The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is:

Erythema toxicum

A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will:

Explain to the parents the action of the medication and answer their questions.

A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom?

Jaundice

To accurately measure the neonate's head, the nurse places the measuring tape around the head:

Just above the ears and eyebrows

A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as:

Low birth weight

A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication?

Meconium aspiration syndrome

A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following?

Neonatal withdrawal or Abstinence syndrome

Heat loss through radiation can be reduced by:

Placing crib near a warm wall

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, difficult to palpate posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner?

Point of maximum intensity

Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level?

Poor feeding

The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan?

Remove strings from infant sleepwear

The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of:

Surfactant

Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is:

Teaching proper techniques for latching-on and releasing of suction

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first?

The baby with temperature 96.3°F, length 17 inches

A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate?

Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.