NSG 333 Ch 23- Nursing Care of the Newborn with Special Needs

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

45 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns." Explanation: The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities.

The mother of a preterm infant tells her nurse that she would like to visit her newborn in the neonatal intensive care unit (NICU). Which response by the nurse would be most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold him, however." Explanation: The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn. Both actions will help make the child's birth more real to them.

An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." Explanation: The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their infant. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement?

"If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." Rationale: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours.

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has occurred when a participant makes which statement?

"Newborns who are appropriate-for-gestational-age at birth have lower chance of complications than others." Explanation: Birth weight variations include appropriate-for-gestational-age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate-for-gestational-age have lower morbidity and mortality than other groups.

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." Explanation: The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.

A client expresses concerns that her grandmothers had complicated pregnancies. What principle(s) should the nurse discuss to allay the fears of the client? Select all that apply.

"We work to ensure that birth of high-risk infants happens in settings where we are able to care for them." "We will work with you to identify prenatal risk factors early and take actions to reduce their impact." "We support those at risk of having a preterm births with the goal of delaying early births." "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." Rationale: The nurse will attempt to allay the client's fears by discussing the actions the facility enacts to promote a healthy brith and infant. This includes ensuring the birth of high-risk infants takes place in settings that have the technological capacity to care for them, identifying risk factors early and taking action to reduce their impact, working to delay the birth of those pregancies identified at risk of preterm birht, and promoting an overall reduction in infant illness, disability, and death to proper care of the mother and infant. Although allowing a family to greive in instances of infant death, discussing this factor with the client is likely to create more fear.

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Explanation: Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention?

30 mg/dl (1.67 mmol/l) Explanation: Hypoglycemia in a neonate is defined as blood glucose value typically below 35 to 45 mg/dl (1.94 to 2.50 mmol/l). The American Academy of Pediatrics recommends intervening for a blood glucose less than 40 mg/dl (2.25 mmol/l) in the first 4 hours of life, and less than 45 mg/dl (mmol/l) at ages 4 hours to 24 hours.

A set of newborn twins has been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply.

A1C levels of 8% (0.08) heroin use disorder blood pressure baseline of 170/90 mm Hg age 39 years multiple gestation Rationale: Assessment of the small-for-gestational-age (SGA) or FGR infant begins by reviewing the maternal history to identify risk factors such as maternal age over 30 years, a substance use disorder, hypertension, multiple gestation. Gestational diabetes or diabetes mellitus is also a factor. Normal A1C level is 5.7% (0.57) for a person without diabetes. Hemoglobin is normal for pregnant woman in third trimester.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally. Explanation: The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl (1.28 mmol/L). The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously. Explanation: The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg/dL (2.22 mmol/L), and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand.

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

Answer: 0.3 Rationale: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and ventilation. epinephrine: 1:10,000 concentration 0.1 to 0.3 mL/kg IV 3000 grams = 3 kg 3 kg x 0.1 mL/kg = 0.3 mL

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss Encourage skin-to-skin contact. Rationale: Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth.

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

Avoid coming to work when ill. Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Explanation: To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.

A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply.

BMI 17.5 prenatal history homelessness prenatal care Rationale: The key to identifying a newborn with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a newborn at risk. These factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of previous preterm birth.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant. Explanation: The infant will receive basic immunization based on chronologic age and standard criteria for administration.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle. Explanation: The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.

The obstetrics nurse has admitted a large-for-gestational-age infant, 1-hour old, for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn. Explanation: Hypoglycemia in a neonate is defined as a blood glucose value below 40 mg/dL (2.22 mmol/L). Supervised breastfeeding or formula feeding may be the initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcomes, and hence aggressive screening and treatment are recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.

A client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams). What priority assessment should be completed by the nurse?

Blood glucose Rationale: Hypoglycemia is a common concern with a large-for-gestational age (LGA) infant. This infant will deplete the glucose stores very rapidly. Therefore, it is important to assess the glucose level within 30 minutes of birth and to repeat every hour until stable. Hypoglycemia is defined as a gluose level less than 35 to 45 mg/dl (1.94 to 2.50 mmol/l) in the first 4 hours of life, and intervention should occur when the glucose is less than 40 mg/dl (2.22 mmol/l). Intervention should also occur if the blood glucose is less than 45 mg/dl (2.50 mmol/l) at 4 and 24 hours of life respectively. Generally the nurse assesses symptoms of jitteriness, irritability and tachypnea first. These symptoms can progress to temperature instability, lethargy, bradycardia, hyponia and seizures.

Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretiohs. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next?

Clear the airway with a bulb syringe. Rationale: After placing the newborn's head in a neutral position, the nurse would clear the airway with a bulb syringe or suction. This is followed by assessment of breathing and bagging if needed, placing a pulse oximeter, ventilating the newborn, assessing the heart rate and giving chest compressions if needed, and then admnistering epinephrine and/or volume expansion if needed.

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. Explanation: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with the ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

Encourage the parents to touch their preterm newborn. Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume. Explanation: The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.

A full-term infant with spontaneous respiration at birth begins exhibiting signs of respiratory distress syndrome (RDS) at 22 hours of age. Which condition would the nurse assess for in this infant?

Group B streptococcus (GBS) infection Explanation: A group B streptococcal infection may mimic RDS because this infection is so severe in newborns that it stops surfactant production. Meconium aspiration syndrome would be preceded by the presence of meconium in the amniotic fluid at birth.

A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply.

Heart rate is 180 beats per minutes Oxygen saturation level is 88% The infant has facial grimacing and quivering chin. Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the normal blood pressure, pulse, and respiration are noted.

An infant is suffering from neonatal abstinence syndrome. The nurse provides appropriate care and support for the infant during the infant's time on the unit. Besides nursing and medical care, what other step would the nurse take to support the infant?

Link the family with community sources for aid. Explanation: Besides nursing care, the nurse would make sure that interdisciplinary members of the team were involved, such as the doctor, nutritionist, and community worker, and provide a supportive environment for the family and the client. The chaplain may not be support for infant or family may not be present. The bright room is overly stimulating to the withdrawing infant, and feeding is basic care.

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply.

Obtain hemoglobin and hematocrit laboratory tests Provide early feedings to prevent hypoglycemia Maintain oxygen saturation parameters Monitor urinary output Rationale: Polycythemia in a neonate is defined as a hematocrit above 65% (0.65) and a hemoglobin level above 20 g/dl (200 g/l). The hematocrit and hemoglobin peak between 6 and 12 hours of life and then start to decrease. If these values do not decrease as expected, then hypoperfusion will occur and polycythemia will develop. In the beginning, the nurse may assess feeding difficulties, hypoglycemia, jitteriness and respiratory distress. As the condition worsens, a ruddy skin color could be seen, cyanosis could develop, the neonate could become lethargic and seizures could develop. Nursing care for this neonate requires obtaining hematocrit and hemoglobin laboratory tests at 2 hours, 12 hours and 24 hours. Feeding should be started to provide fluid, nutrition and prevent hypoglycemia. The oxygen saturation should be monitored. If the levels are below the established parameters from the health care provider, oxygen therapy will be needed. The urine output should be monitored continuously because polycythemia can cause real failure. A peripheral IV may or may not be needed. This would depend on the neonate's condition and if IV fluids would be required.

A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply.

Offer to pray with the family if appropriate. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Respect variations in the family's spiritual needs and readiness. Rationale: When assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family's spiritual needs and readiness. The nurse will also initiate spiritual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate.

A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings Rationale: The nurse must consider the implications of a small-for-gestational-age newborn. With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for newborn reflexes, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how he or she is turned. Explanation: Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn?

Provide opportunities for them to hold the newborn. Rationale: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?

The infant was a preterm, low-birth-weight and small-for-gestational-age Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

A macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. For which would the nurse assess? Select all that apply.

facial grimacing with movement bruising over area asymmetrical movement edema present Rationale: Birth trauma for LGA newborns would be demonstrated by an obvious deformity, with bruising at the site and edema noted. There would be asymmetrical movement when the newborn moves the limb. Babinski reflex is a neurological test and would be normal to be positive.

A term neonate has been admitted to the observational newborn nursery with the diagnosis of being small for gestational age. Which factors would predispose the neonate to this diagnosis? Select all that apply.

The mother had chronic placental abruption At birth the placenta was noted to be decreased in weight On assessment the placenta had areas of infarction. At birth the placenta was a shiny Schultz presentation. Rationale: Placental factors that can contribute to a small for gestational age infant include chronic placental abruption, infarction on surface of placenta, and a decreased placental weight. A shiny Schultz placenta is a normal description because the fetal side of the placenta comes out first, which is shiny. Placenta talipes does not exist.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age. Rationale: Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology.

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Explanation: Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed. Rationale: Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile Explanation: A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an en face position Explanation: To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. Which type of solution would the nurse most likely administer for the feeding?

breast milk Explanation: Currently, minimal enteral feeding is used to prepare the preterm newborn's gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts of breast milk or enteral feeding to induce surges in gut hormones that enhance maturation of the intestine. This minute amount of breast milk or formula given via gavage (tube) feeding prepares the gut to absorb future introduction of nutrients. It builds mucosal bulk, stimulates development of enzymes, enhances pancreatic function, stimulates maturation of gastrointestinal hormones, reduces gastrointestinal distention and malabsorption, and enhances transition to oral feedings. All of the expert committees recommend the use of human milk, which reduces the risk of necrotizing enterocolitis, a serious disease of preterm infants in the neonatal period. Saline or sterile water are not used.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction Explanation: A conduction heat loss results from direct contact with an object that is cooler.

A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn?

diabetes Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes postdates gestation prepregnancy obesity Explanation: Diabetes, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn being large for gestational age.

The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation?

difficulty in arousing to a quiet alert state Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb, 13 oz (3,997 g) at term.

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels (fontanelles) Explanation: When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels (fontanelles). Sunken fontanels (fontanelles) suggest dehydration; bulging fontanels (fontanelles) suggest overhydration.

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn?

greater body surface area in proportion to weight Rationale: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body Explanation: A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large-for-gestational-age (LGA) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant?

hypoglycemia Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

increased serum bilirubin levels clay-colored stools tea-colored urine Rationale: Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing Explanation: The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability.

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as:

late preterm Rationale: Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation.

A term neonate required resuscitation after birth with positive-pressure ventilation for 5 minutes. The nurse is providing post-resuscitation observation and care in the nursery (above). What abnormal finding does the nurse expect in this neonate?

low glucose due to energy expenditures during resuscitation Explanation: This neonate's blood glucose is below normal. During resuscitation, the neonate often expends additional glucose with attempts to breathe and hypoglycemia may result. This is an urgent issue that needs to be treated with glucose or milk administration. This blood pressure and oxygen saturation are normal for a term neonate. Acrocyanosis is also a normal finding.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea Explanation: Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails Explanation: Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanugo; and meconium-stained skin and fingernails.

Which finding is indicative of hypothermia of the preterm neonate?

nasal flaring Explanation: Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist?

ophthalmologist Rationale: Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity (ROP) and further respiratory complications in the preterm newborn (Martin & Deakins, 2020). For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. As a result, an ophthalmology consult for follow-up after discharge is essential for preterm infants who have received extensive oxygen. Although referrals to other specialists may be warranted depending on the newborn's status, there is no information to suggest that any would be needed.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant?

placental factors Explanation: Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption (abruptio placentae), malformed and smaller placentas, with placenta previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia Explanation: Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? Select all that apply.

poor sucking respiratory distress weak cry jitteriness Rationale: Some of the common problems associated with newborns experiencing a variation in gestational age, such as a postterm newborn, are respiratory distress, jitteriness, feeble sucking, weak cry, and a blood glucose of 40 mg/dl.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm Explanation: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

A nurse is assisting with the resuscitation of a preterm newborn. Which assessment would help assist the team in determining that the resuscitation efforts have been successful?

pulse rate of 110 beats per minute Explanation: Resuscitation measures are continued until the newborn has a pulse above 100 bpm, a good healthy cry or good breathing efforts, and a pink tongue. This last sign indicates a good oxygen supply to the brain. Conjunctival assessment would be of no benefit. A respiratory rate of 10 breaths per minute alone does not indicate the respiratory effort.

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:

respiratory distress Rationale: Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time.

A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply.

ruddy skin color respiratory distress cyanosis jitteriness Rationale: Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results.

A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain?

sudden high-pitched cry Rationale: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

swaddling the newborn closely offering a pacifier prior to a procedure encouraging skin-to-skin (kangaroo) care during procedures Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging skin-to-skin (kangaroo) care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine Explanation: Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?

term, small-for-gestational-age, and low-birth-weight infant Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).

A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? Select all that apply.

the age of the client living in a shelter for victims of intimate partner violence vaginal bleeding blood pressure positive test for TORCH Rationale: Some factors contributing to the birth of SGA newborns include maternal age of 20 or 35 years old, low socioeconomic status, and preeclampsia with increased blood pressure. The vaginal bleeding indicates placental problems, and she tests positive for sexually transmitted diseases by TORCH group infections.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,:

the ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

the pressure the nurse uses when the hand squeezes against the bag Explanation: The pressure exerted by the nurse's hand squeezing the bag controls the pressure delivered by an anesthesia bag. An ambu or resusci bag has a blow-off value that limits the pressure administered.

A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation?

thin umbilical cord Rationale: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes Explanation: Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa.

The nurse determines a newborn is small-for-gestational-age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores Explanation: The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.

After completing an assessment of a newborn, the nurse determines that the newborn is small-for-gestational-age based on which weight assessment?

weight of 2,400 g Explanation: Small-for-gestational-age newborns typically weigh less than 2,500 g (5 lb 8 oz) at term due to less growth in utero than expected. Newborns who weigh from 2,500 g to 4,000 g (8 lb 13 oz) are considered appropriate for gestational age. Infants over 4,000 g are described as large-for-gestational-age newborns.