Nursing Care: High-Risk Newborn - Acquired Conditions
A postterm newborn is born with thick, green amniotic fluid. The neonatal intensive care team is present at delivery and the newborn is not responding to interventions. No respiratory effort is noted. The nurse should (assist with intubation or place the newborn) in the prone position.
Assist with intubation Newborns with meconium-stained fluid should be cared for according to normal newborn protocols, which include warming, clearing secretions, and assessing for respiratory efforts. If the newborn does not respond to interventions, intubation may be needed for additional respiratory support and suctioning. The nurse will assist the care team in the intubation. The newborn should be placed in a supine position, not a prone position, during post-delivery assessment and resuscitation efforts.
4 of 6 The nurse should include which of the following in planning for the newborn's care at delivery? Select all that apply. Bag and mask Oxygen supply Additional assistance Removing visitors Suction set-up
Bag and mask Oxygen supply Additional assistance Suction set-up
The nurse is providing teaching for a client who recently became pregnant. Which substances should be avoided to prevent the client from toxoplasmosis? Reheated rice Unfortified cereals Goat cheese Cat feces Raw eggs Uncooked meats
Cat feces Uncooked meats ---- Toxoplasmosis is transmitted to humans via consumption of undercooked meat containing cysts or ingestion of cysts from cat feces. Pregnant women should steer clear of soft goat cheeses that are surface-ripened or made from raw, unpasteurized goat milk due to the increased risk of listeriosis and/or E. coli. There is no danger from unfortified cereals, except that they are empty calories. Rice is more problematic than some other leftover foods as it may contain bacteria called Bacillus cereus, which survive some cooking processes. This bacterium is often the cause of food poisoning from reheated or cooked rice.
2 of 6 What potential issues might the newborn be at risk for based on the information? Select all that apply. Cephalohematoma Fetal hypoxia Elevated newborn blood sugar Respiratory depression Sepsis
Cephalohematoma Fetal hypoxia Respiratory depression Sepsis ----- At 42 weeks of gestation, there may be less placental reserve and uteroplacental insufficiency is more common. Fetal passage of meconium in utero may be a sign of fetal hypoxia and presents a risk to effective neonatal respiration following birth. Repetitive late fetal heart rate decelerations accompanied by decreased variability are indicative of fetal hypoxia, usually secondary to uteroplacental insufficiency. A maternal fever may be a sign of chorioamnionitis, which increases the risk of sepsis in the newborn. The use of a vacuum to expedite vaginal birth increases the risk for fetal scalp lacerations, cephalohematoma, and subdural hemorrhage. There is no connection with elevated blood sugars.
Recognizing Cues 1 of 6 A 26-year-old gravida 1 para 0 (G1P0) at 42 weeks of gestation is 10 cm dilated, fully effaced, and +1 station. The healthcare provider is at the bedside preparing for delivery. There were no pregnancy complications. Labor was complicated by meconium-stained amniotic fluid and repetitive late fetal heart rate decelerations with decreased variability during the past 1.5 hours of labor. The client also developed a fever of 101°F in the last hour of labor with cefoxitin ordered and administered intravenously (IV). A cesarean section was considered due to fetal intolerance of labor, however, the healthcare provider decided to deliver the fetus vaginally with vacuum extraction. Select whether each finding below should be a concern or not to the nurse. Concern Not a Concern 26-year-old gravida 1 para 0 42 weeks of gestation Meconium-stained amniotic fluid Repetitive late fetal heart rate decelerations with decreased variability Fever of 101°F Started on cefoxitin IV Fetal intolerance of labor Vacuum extraction
Concern - 42 weeks of gestation - Meconium-stained amniotic fluid - Repetitive late fetal heart rate decelerations with decreased variability -Fever of 101°F -Fetal intolerance of labor -Vacuum extraction Not concern 26-year-old gravida 1 para 0 Started on cefoxitin IV
Transient tachypnea of the newborn (TTN) is caused by (delayed absorption of fetal lung or fluid hypoinflation of the lungs). A respiratory rate of (28or 70) and (grunting or gasping) are common signs.
Delayed absorption of fetal lung fluid 70 Grunting ------ Transient tachypnea of the newborn (TTN) is caused by excess fetal lung fluid that hasn't been absorbed. The respiratory rate is elevated so, with a normal range of 30-60, 70 respirations per minute is a sign of TTN. Grunting, retractions, and nasal flaring may be present.
A nurse is planning orientation for a new nurse graduate. What is the most important nursing action for preventing neonatal infection? Personal protective equipment (PPE) gown protocols Isolation of infected infants Good handwashing Standard precautions
Good handwashing --------- Handwashing is important for the prevention of healthcare-associated infection in nursery units. It is very important to track census and overcrowding must be avoided in nurseries. Infants who are positive for infections should be isolated. Nurses should change gowns between each infant assessment/interaction. Soiled linens should be disposed of in an appropriate manner. Measures to be taken include: standard precautions careful and thorough cleaning frequent replacement of used equipment disposal of excrement and linens in an appropriate manner ideally, infants should remain with their mothers in the room whenever possible
5 of 6 At birth, the newborn is pale and limp with poor respiratory effort and a weak cry. Pulse 110. Identify which potential actions or interventions are Indicated Nonessential Contraindicated Place the newborn under the radiant warmer Place the newborn in a prone position Suction the airway Complete Ballard assessment
Indicated - Place newborn under the radiant warmer -Suction the airway Nonessential Complete the ballard assessment Contraindicted Place the newborn in a prone position
A client delivered a 9 lb 10 oz infant. Which condition should the nurse be aware of related to skeletal injuries sustained by a neonate during labor or childbirth? Most linear skull fractures heal without special treatment. The newborn's skull is still forming and unfused, and fractures fairly easily. A pin is often needed to stabilize clavicle fractures. Other than the skull, the most common skeletal injuries are to leg bones.
Most linear skull fractures heal without special treatment. -------- Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.
The nurse is planning the care of a 2-hour-old newborn post delivery. The newborn's clavicle was fractured during delivery due to shoulder dystocia. Which intervention should the nurse include in the plan of care? Teach parents range-of-motion exercises Place newborn in prone position Immobilize affected arm with a soft fabric splint Pin sleeve of the affected arm to the shirt
Pin sleeve of the affected arm to the shirt ------------ Fractures in newborns generally heal rapidly. Except for gentle handling and immobilization by pinning the sleeve of the affected arm across the chest to the shirt, no treatment for a fractured clavicle is needed. Performing range-of-motion exercises on the newborn is not part of the plan of care. A fractured clavicle does not require immobilization with a splint. The prone position is not encouraged unless the newborn is under surveillance. The newborn should stay in a supine position to prevent sudden infant death syndrome (SIDS).
An HIV positive client will be delivering in the next 24 hours. Which statement regarding the methods of transmission from mother to fetus/child is most accurate? Only in the second trimester from the maternal circulation From the use of unsterile forceps Only through the ingestion and contact with amniotic fluid Through the ingestion of breast milk from an infected mother
Through the ingestion of breast milk from an infected mother ----------- Postnatal transmission of HIV through breastfeeding and breast milk may occur. Transmission of HIV from the mother to the fetus may occur through the placenta at various gestational ages. Transmission of HIV from the use of unsterile instruments is highly unlikely; most healthcare facilities must meet sterility standards for all instrumentation.
6 of 6 For each assessment finding, click to specify if it indicates that the newborn's condition has improved or not changed. Pulse 148 Arms flexed Color pink with acrocyanosis Weak cry
improved Pulse 148 Arms flexed Color pink with acrocyanosis Not changed Weak cry ------ Increased muscle tone, increased heart rate, and improved color indicate improving oxygenation. The newborn continues to have weak crying efforts but the heart rate, color, and muscle tone are improving.
3 of 6 The priority concern the nurse should prepare for in anticipation of the impending delivery is (sepsis or cephalohematoma or respiratory depression.
respiratory depression. ----- The priority concern the nurse should prepare for in anticipation of the impending delivery is respiratory depression. Fetal passage of meconium in utero presents a risk to effective neonatal respiration following birth. Repetitive late fetal heart rate decelerations accompanied by decreased variability are indicative of fetal hypoxia, also increasing risk of respiratory distress at birth.
A newborn born three hours ago to a mother with type 1 diabetes is at risk for (respiratory distress syndrome or sepsis) related to increased (inadequate production of surfactant or white blood cells).
respiratory distress syndrome inadequate production of surfactant --------- Newborns born to mothers with type 1 diabetes are at risk for macrosomia, perinatal asphyxia, respiratory distress syndrome (RDS), hypoglycemia, hypocalcemia, hypomagnesemia, and hyperbilirubinemia. Increased levels of insulin have a blocking effect on cortisol, which stimulates lung maturation, leading to respiratory distress syndrome. They are not at risk for sepsis related to elevation of white blood cells.
he nurse is teaching a prenatal class and a mom shares that she does not want any antibiotics given to her baby after delivery. Which statement by the nurse explains the need for the use of erythromycin ointment on newborns? "The hospital does not use humidified air, so the drops will keep the infant's eyes from drying out." "It is to protect your baby from contracting herpes from your vaginal tract." "It improves a newborn's vision and prevents the need for glasses as they get older." "Erythromycin is given to prevent an eye infection from gonorrhea."
"Erythromycin is given to prevent an eye infection from gonorrhea." ------ With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has significantly declined. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is given to prevent infection, not for lubrication.
A nurse is caring for a 1-day-old newborn delivered via cesarean section with APGAR scores of 6 at 1 minute and 7 at 5 minutes after prolonged rupture of membranes. The mother shares that the newborn has not been feeding well and is concerned that something is not right. The nurse should assess for other signs of which most likely condition? Sepsis Hyperglycemia Transient tachypnea of the newborn Respiratory distress syndrome
Sepsis ----------- The signs of sepsis can be subtle and include poor feeding, temperature instability, and changes in color or tone. Sometimes, parents may also share that they feel something is not right with their newborn. The report from the mother should cue the nurse to suspect the potential for sepsis, especially given the risk factor of a prolonged rupture of membranes prior to delivery. When prolonged rupture of membranes occurs during labor, organisms from the vagina are more likely to ascend into the uterine cavity and ultimately to the fetus. Poor feeding is not a sign of hyperglycemia. While transient tachypnea of the newborn and respiratory distress syndrome may lead to difficulty with feedings, the most likely condition is sepsis due to the key information related to prolonged rupture of membranes.
