Nursing Care of the Newborn
As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. Which infant behavior will assist the nurse in identifying this problem? A. Crying B. Inhaling C. Suckling D. Sleeping
A. Crying Increased intraabdominal pressure associated with crying, coughing, or straining will cause protrusion of the hernia. Lowering of the diaphragm may increase intraabdominal pressure slightly but not enough to cause protrusion of an umbilical hernia. Suckling and sleeping do not increase intraabdominal pressure.
Five minutes after birth, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score? Record your answer using a whole number. _____
5 The Apgar score is 5. According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen.
In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? A. Documenting an intact reflex B. Assessing the infant's vital signs C. Testing the infant's ability to hear D. Stimulating the infant's respirations
A. Documenting an intact reflex The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the response to the stimulus decreases. This decrease in response is called habituation and is expected. Assessing the infant's vital signs and stimulating the infant's respirations are not necessary because the neonate's response is expected. The infant is responding to noise and therefore hears.
A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action? A. Feeding the infant B. Requesting a complete blood count C. Monitoring the infant for hyperthermia D. Allowing the infant to rest undisturbed
A. Feeding the infant A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. The blood count will not change during a transient hypothermic episode. If the hypothermic period is treated adequately, hyperthermia is not expected to develop. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply. A. "Wash your hands before touching the newborn." B. "Send the newborn to nursery to be monitored during the night." C. "All client identification bands should remain in place until discharge." D. "Do not let anyone remove the infant from your sight while you are in the hospital." E. "Check the identification of staff, and if there is a question of validity, call the nursing station."
A. "Wash your hands before touching the newborn." C. "All client identification bands should remain in place until discharge." E. "Check the identification of staff, and if there is a question of validity, call the nursing station." Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take the infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.
A 7 lb, 4 oz (3289 g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe? A. By suctioning the mouth before the nostrils B. By starting the oxygen and then suctioning the pharynx C. By positioning the bulb far into the throat before beginning suctioning D. By placing the bulb in the mouth, compressing the bulb, and starting suctioning
A. By suctioning the mouth before the nostrils The mouth is suctioned before the nostrils because if the nostrils are suctioned first a reflex gasp may be stimulated, resulting in aspiration of mucus from the mouth. The newborn will be unable to inhale oxygen or even breathe if the nose and throat are occluded with mucus. Placing the bulb too far into the mouth may cause trauma or reflex bradycardia. The bulb should be compressed before it is placed in the newborn's mouth; timing of bulb compression is essential, or mucus may be forced farther into the throat.
The nurse is assessing a newborn in the birthing room. Which finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life? A. Central cyanosis B. Flexed extremities C. Heart rate of 130 beats/min D. Respiratory rate of 40 breaths/min
A. Central cyanosis Cyanosis of the lips, mucous membranes, and face indicates diminished oxygenation of the blood, caused by either decreased lung expansion or right-to-left shunting of blood. Flexed extremities, a heart rate of 130 beats/min, and a respiratory rate of 40 breaths/min are expected in the healthy newborn.
A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. Which condition does the nurse suspect? A. Chlamydia trachomatis infection B. Human immunodeficiency virus (HIV) infection C. Retinopathy of prematurity (retrolental fibroplasia) D. A reaction to the ophthalmic antibiotic instilled after birth
A. Chlamydia trachomatis infection Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.
The nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? A. Flaring nares B. Acrocyanosis C. Heartbeat of 140 beats/min D. Respirations of 40 breaths/min
A. Flaring nares Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and to increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the newborn.
Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Select all that apply. A. Flexed fetal position B. Hepatic insulin stores C. Brown fat metabolism D. Peripheral vasoconstriction E. Parasympathetic nervous system
A. Flexed fetal position C. Brown fat metabolism D. Peripheral vasoconstriction Full-term neonates maintain a flexed fetal position, which conserves heat. Deposition of brown fat begins at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps conserve heat by keeping the central core warm and preventing heat from dissipating. Insulin is not stored in the liver and is not involved with maintenance of neonatal body temperature. The sympathetic, not parasympathetic, nervous system is involved in thermoregulation.
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time? A. Helping the client change her position B. Informing the client of the problem with the fetus C. Administering oxygen by mask to the client at 2 L/min D. Readjusting placement of the fetal monitor on the client's abdomen
A. Helping the client change her position Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because this position change will increase placental perfusion. Although the client should be kept informed of the fetus's condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min. Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority.
The nurse knows that the newborns of mothers with diabetes often exhibit tremors, periods of apnea, cyanosis, and poor suckling ability. With which complication are these signs associated? A. Hypoglycemia B. Hypercalcemia C. Central nervous system edema D. Congenital depression of the islets of Langerhans
A. Hypoglycemia The pancreas of a fetus of a diabetic mother responds to the mother's hyperglycemia by secreting large amounts of insulin; this leads to hypoglycemia after birth. Hypocalcemia, not hypercalcemia, occurs. Edema may be generalized, not specific to the central nervous system. In response to the increased glucose received from the mother, the islets of Langerhans in the fetus may become hypertrophied; these cells are not congenitally depressed.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? A. In utero through the placenta B. In the postpartum period through breast milk C. During birth through contact with the maternal vagina D. After the birth through a blood transfusion given to the mother
A. In utero through the placenta Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.
A client exhibits oligohydramnios at 36 weeks' gestation. What newborn complication should the nurse anticipate? A. Spina bifida B. Imperforate anus C. Tracheoesophageal fistula D. Intrauterine growth restriction (IUGR)
A. Intrauterine growth restriction (IUGR) Oligohydramnios is associated with IUGR; risk factors for IUGR include inadequate maternal nutrition and other high-risk conditions such as diabetes and preeclampsia. Spina bifida does not affect amniotic fluid volume; it is associated with an increased alpha-fetoprotein level. Imperforate anus does not affect amniotic fluid volume. Tracheoesophageal fistula is often associated with polyhydramnios, which is excessive amniotic fluid.
The nurse is assessing a 12-hour-old newborn. Which clinical finding should be reported to the health care provider in a timely manner? A. Jaundice B. Cephalhematoma C. Erythema toxicum D. Edematous genitalia
A. Jaundice Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, how does the nurse identify them? A. Milia B. Lanugo C. Whiteheads D. Mongolian spots
A. Milia Milia are common, they are not indicative of illness, and they eventually disappear. Lanugo is fine, downy hair. Whiteheads are a lay term for milia; the term is not used in documentation. Mongolian spots are bluish-black areas on the buttocks that may be present on dark-skinned infants.
In specific situations gloves are used to handle newborns whether or not they are positive for human immunodeficiency virus (HIV). When is it unnecessary for the nurse to wear gloves while caring for a newborn? A. Offering a feeding B. Changing the diaper C. Giving an admission bath D. Suctioning the nasopharynx
A. Offering a feeding Standard precautions do not include the use of gloves for feeding. Wearing clean gloves for diaper changes of newborns is standard protocol. Clean gloves should be worn for all admission baths, because the nurse will be exposed to blood and amniotic fluid. Clean gloves should also be worn while the nurse suctions an infant.
The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately? A. Placing the naked infant on the scale B. Removing the infant's clothes except for the diaper before weighing C. Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight D. Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight
A. Placing the naked infant on the scale Placing the naked infant on the scale is the most accurate method of weighing an infant because it removes all variables that could influence the weight. Removing the infant's clothes except for the diaper before weighing will result in an inaccurate measurement because the diaper and its contents have mass and will add to the measurement. Weighing the infant's clothes and then subtracting that weight from the infant's weight adds an unnecessary step to the procedure. An adult scale does not have the fine increments that are needed to obtain an accurate weight for an infant.
The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a preterm gestational age? A. Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant B. Skin: parchment/wrinkled; breasts: flat areolae, no buds; plantar creases: cover entire sole; lanugo: absent C. Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: covering the entire sole; lanugo: abundant D. Skin: cracking/few veins; breasts: raised areolae (3- to 4-mm buds); plantar creases: covering the anterior two thirds of the sole; lanugo: thinning
A. Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo: abundant The characteristics of preterm, term, and postterm gestational age are based on assessments of physical maturity such as the Ballard or Dubowitz assessment. A preterm infant's skin is translucent, with many visible veins. A term infant has some cracking of the skin and some visible veins, depending on gestational age. Term is any gestation after 38 weeks; veins are less visible at 40 weeks' gestation. The postterm infant typically has dry, leathery, parchmentlike skin with numerous deep wrinkles. The areolae of a preterm infant are flat, without buds, and they become more raised during development, averaging 3 to 4 mm at term and 5 to 10 mm in the postterm infant. The plantar creases develop on the foot during gestation, beginning smooth, then covering two thirds at term, and finally covering the entire sole after term. Lanugo is the fine downy hair that diminishes as the infant develops gestationally.
Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits what sign? A. Supraventricular retractions B. Tachycardia of 160 beats/min C. Respirations of 50 to 60 breaths/min D. Neonatal Infant Pain Scale (NIPS) score of three
A. Supraventricular retractions Supraventricular retractions are a prominent feature of respiratory problems in preterm infants because of their compliant chest walls. Tachycardia of 160 beats/min is within the expected range of 110 to 160 beats/min. A rapid respiratory rate of 40 to 60 breaths/min is expected in neonates.A NIPS score of three alone does not indicate a need for immediate nursing intervention for respiratory distress syndrome.
A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse? A. "I'll get your grandchild. You must be very excited." B. "Please go on to see your daughter. I'll bring the baby to her room." C. "Show me your identification. I need to see it before I can give you the baby." D. "Only the mother can ask for the baby. Have her call us to bring the baby to her."
B. "Please go on to see your daughter. I'll bring the baby to her room." Telling the couple that the baby will be brought to the client's room maintains the nurse's legal responsibility of providing for the infant's safety while still promoting a positive interaction with the client's family. Giving the infant to another person without the mother's knowledge or consent is illegal. Legally the nurse may not give the infant to the grandparents. Although insisting that only the mother can ask for the infant may follow legal policy, it is an abrupt nontherapeutic response to the grandparents.
An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the newborn. Which dosage and route will the nurse use? A. 1.0 to 1.5 mg given intramuscularly B. 0.5 to 1.0 mg given intramuscularly C. 1.0 to 1.5 mg given subcutaneously D. 0.5 to 1.0 mg given subcutaneously
B. 0.5 to 1.0 mg given intramuscularly The correct dosage of vitamin K is 0.5 to 1.0 mg, and the correct route is intramuscular. Vitamin K is not given to infants subcutaneously.
A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns require about 73 mL of fluid per pound (454 g) of body weight each day. In light of this information, approximately how much formula should the infant receive at each feeding? A. 1 to 2 oz (30 to 60 mL) B. 2 to 3 oz (60 to 90 mL) C. 3 to 4 oz (90 to 120 mL) D. 4 to 5 oz (120 to 150 mL)
B. 2 to 3 oz (60 to 90 mL) Infants require about 73 mL of fluid per pound (454 g) and 60 calories a day per pound (454 g) for growth. The infant's weight of 6 lb × 73 mL of fluid = 438 mL (2722 g/454 g x 73 mL = 438 mL). If fed every 4 hours the infant will have six feedings: 438 ÷ 6 = 73 mL; 73 ÷ 30 (30 mL/oz) = 2.4 oz (73 mL per feeding). Therefore the infant should be offered 2 to 3 oz (60 to 90 mL) per feeding. One or 2 oz (30 to 60 mL) is inadequate for this newborn. Three to 5 oz (90 to 150 mL) is excessive for this newborn.
An infant born in a birthing center is being transferred to a regional neonatal intensive care unit because of respiratory distress. Which nursing action best promotes parent-infant attachment? A. Encouraging the parents to call their infant by name B. Allowing the parents to hold their infant before departure C. Giving the parents a picture of their infant in the intensive care unit D. Instructing the parents to contact the neonatal intensive care unit daily
B. Allowing the parents to hold their infant before departure Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant's progress.
An infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. What is the priority nursing intervention at this time? A. Having the hospital chaplain visit the parents B. Assisting the parents with the grieving process C. Obtaining a prescription for a sedative to ease the parents' anxiety D. Arranging for a social worker to talk to the parents about available resources
B. Assisting the parents with the grieving process Parental grieving is expected and necessary whenever an infant is born with severe problems; the parents are grieving the loss of a "normal baby." The parents should make the decision to meet with the chaplain. Obtaining a prescription for a sedative to ease the parents' anxiety may delay processing information and impede the grieving process. Arranging for a social worker to talk to the parents about available resources may be needed later; right now it is too soon to determine the outcome.
The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants? A. Have a smaller body surface area than full-term newborns B. Lack the subcutaneous fat that usually provides insulation C. Perspire excessively, causing a constant loss of body heat D. Have a limited ability to produce antibodies against infections
B. Lack the subcutaneous fat that usually provides insulation Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.
A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? A. Testing the infant's stools for occult blood B. Monitoring the infant's blood glucose level C. Placing the infant in the Trendelenburg position D. Comparing the infant's head circumference and chest circumference
B. Monitoring the infant's blood glucose level SGA infants are prone to hypoglycemia, because they have little subcutaneous fat or glycogen stores. Intestinal bleeding is not common in SGA infants. Placing an SGA infant in the Trendelenburg position is of no therapeutic value. Hydrocephalus or microcephaly is not a characteristic of SGA infants.
During a newborn assessment the nurse identifies the absence of the red reflex in the eyes. What should the nurse's next action be? A. Rinse the eyes with sterile saline B. Notify the primary healthcare provider C. Expect edema to subside within a few days D. Conclude that this is a result of the prescribed eye prophylaxis
B. Notify the primary healthcare provider An absence of the red reflex may be indicative of congenital cataracts. The red reflex is elicited by shining the light of an ophthalmoscope into the newborn's eyes, which should produce a reddish circle. Rinsing the eyes will not affect the red reflex. The red reflex or its absence is not related to edema, which may occur after eye prophylaxis, or to eye prophylaxis itself.
An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor when crying. In light of these assessment findings, which actions should the nurse consider taking next? A. Taking no specific action, because both signs are expected in a newborn until 2 weeks of age B. Notifying the health care provider, because circumoral pallor may signal a cardiac problem C. Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96 hours D. Notifying the health care provider, because cyanosis usually accompanies increased intracranial pressure
B. Notifying the health care provider, because circumoral pallor may signal a cardiac problem Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign. Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis does not indicate increased intracranial pressure.
A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify? A. Closed suture lines B. Open anterior and posterior fontanels C. Elongation of the forehead and occiput D. Soft fluctuating edema that covers the scalp
B. Open anterior and posterior fontanels The fontanels, both anterior and posterior, are open at birth. Closed sutures are unexpected and may prevent brain growth during the first year. Elongation of the head is expected after a vaginal, not a cesarean, birth, because the head shape changes to accommodate the contours of the birth canal. Soft fluctuating edema covering the scalp is caput succedaneum, which may result from trauma during a vaginal birth.
A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited? A. Striking the surface of the crib suddenly B. Stroking the outer sole of the foot from the heel to the little toe C. Maintaining the supine position and applying pressure to the soles of the feet D. Holding the infant's body upright and allowing the feet to touch the surface of the crib
B. Stroking the outer sole of the foot from the heel to the little toe Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Jarring the crib produces a startle response (Moro reflex); the legs and arms extend and the fingers fan out, and the thumb and forefinger form a C. Applying pressure against the soles of the feet produces the magnet reflex; the legs extend in response to the pressure on the soles of the feet. Having the feet touch the surface of the crib produces the stepping reflex; one foot is placed before the other in a simulated walk, with the weight on the toes.
What does a nurse who is assessing a newborn 3 minutes after birth remember is the range of heart rate for a healthy, alert neonate? A. 120 and 180 beats/min B. 130 and 170 beats/min C. 110 and 160 beats/min D. 100 and 130 beats/min
C. 110 and 160 beats/min The newborn's heart rate varies with activity; crying can increase it to 180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110 beats/min constitutes bradycardia.
An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What is the nurse's assessment of the neonate? A. Small for gestational age (SGA) and term B. SGA and preterm C. Appropriate for gestational age (AGA) and term D. AGA and preterm
C. Appropriate for gestational age (AGA) and term Birth between 38 and 42 weeks' gestation is considered term; at term, healthy neonates weigh between 5 lb 10 oz and 8 lb 6 oz (2551 to 3799 g). Although the birth took place between 38 and 42 weeks' gestation (term infant), an SGA infant weighs less than the expected range for the gestational age. A preterm infant is one born before 38 weeks' gestation; the infant's weight is within the expected range for 40 weeks' gestation. Although the infant's weight is appropriate for the gestational age of 40 weeks, the infant is not preterm, because birth occurred between 38 and 42 weeks' gestation.
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment? A. Depressed dance reflex B. Limited adduction of the leg C. Asymmetry of the gluteal folds D. Shortened leg on the unaffected side
C. Asymmetry of the gluteal folds The gluteal folds should be symmetric, as should all planes and folds of the body. An abnormality of the hips will cause asymmetry, a shorter leg on the affected side, or both. The dance reflex is not affected in DDH. With DDH, abduction of the leg is usually limited at the hip. The leg on the affected, not unaffected, side appears to be shorter with DDH.
A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant? A. Less than 40% B. More than 75% C. Between 45% and 65% D. Between 65% and 75%
C. Between 45% and 65% The expected hematocrit level for a healthy newborn is between 45% and 65%. Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.
The nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has what limitation? A. Cannot use shivering to produce heat B. Cannot break down glycogen to glucose C. Has a limited supply of brown fat available to provide heat D. Has a limited amount of pituitary hormones with which to control internal heat
C. Has a limited supply of brown fat available to provide heat Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown of glycogen into glucose does not supply body heat. Pituitary hormones do not regulate body heat.
What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area? A. Remove the cord clamp only after the cord stump has separated. B. Smooth ointment or baby lotion around the cord after the sponge bath. C. Leave the area untouched or clean with soap and water; then pat it dry. D. Wrap an elastic bandage snugly around the waist area over the cord site.
C. Leave the area untouched or clean with soap and water; then pat it dry. Healing is optimal when the area is left alone or, if needed, is washed with mild soap and water and then gently dried. The cord clamp is removed when the cord stump is dry, usually at 24 hours. Ointment and other emollients will keep the cord moist; rapid drying of the cord is preferred. Wrapping an elastic bandage snugly around the waist area over the cord site prevents the cord from drying and provides a dark, warm, moist medium for the growth of organisms.
Which behavior does a nurse expect of a newborn approximately 1 hour after birth? A. Crying and cranky B. Hyperresponsive to stimuli C. Relaxed and sleeping quietly D. Intensely alert with eyes wide open
C. Relaxed and sleeping quietly It is expected that a newborn will enter a sleep phase about 30 minutes after birth. After the initial cry, the baby will settle down and become quiet and alert. Hyperresponsiveness to stimuli occurs after the first sleep. Intense alertness with eyes wide open occurs during the first period of reactivity.
What is the most common complication for which a nurse must monitor preterm infants? A. Hemorrhage B. Brain damage C. Respiratory distress D. Aspiration of mucus
C. Respiratory distress Immaturity of the respiratory tract in preterm infants is evidenced by a lack of functional alveoli, smaller lumina with increased possibility of collapse of the respiratory passages, weakness of respiratory musculature, and insufficient calcification of the bony thorax, leading to respiratory distress. Hemorrhage is not a common occurrence at the time of birth unless trauma has occurred. Brain damage is not a primary concern unless severe hypoxia occurred during labor; it is difficult to diagnose at this time. Aspiration of mucus may be a problem, but generally the air passageway is suctioned as needed.
The primary healthcare provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time? A. Bringing the infant as requested before she changes her mind B. Describing how the infant looks before bringing the infant to her C. Staying with her after bringing the infant to help her verbalize her feelings D. Showing the mother pictures of the birth defects, then bringing the infant to her
C. Staying with her after bringing the infant to help her verbalize her feelings Allowing the client time to talk about her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature.
While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond? A. "Flat feet are more common in children than adults." B. "That's hard to assess because the feet are so small." C. "There may be a bone defect that needs further assessment." D. "Infants' feet appear flat because the arch is covered with a fat pad."
D. "Infants' feet appear flat because the arch is covered with a fat pad." A fat pad covers the arch in newborns and infants; the arch develops when the child begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant; arch development is related to walking. Flat feet are not associated with deformities of the bones.
A nurse is assessing a newborn in the well baby nursery. What type of respirations does the nurse expect to identify in a healthy newborn? A. Deep and retracting B. Shallow and thoracic C. Stertorous and regular D. Abdominal and irregular
D. Abdominal and irregular A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.
Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0 °F (36.7 °C) and 97.4 °F (36.3 °C) would be considered critical? A. Respiratory rate of 60 breaths/min B. White blood count greater than 15,000 mm3 C. Serum calcium level of 8 mg/dL (2 mmol/L) D. Blood glucose level of 26 mg/dL (1.4 mmol/L)
D. Blood glucose level of 26 mg/dL (1.4 mmol/L) Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 30 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm3 are all normal findings and do not affect body temperature.
A newborn is circumcised prior to discharge from the hospital. What should the immediate postoperative care include? A. Keeping the infant NPO for 4 hours to prevent vomiting B. Encouraging the intake of alkaline fluids to reduce urine acidity C. Changing the dressing using dry, sterile gauze to maintain cleanliness D. Encouraging the mother to cuddle her baby to provide emotional support
D. Encouraging the mother to cuddle her baby to provide emotional support Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Removal of dry gauze will cause bleeding; sterile petrolatum gauze is used and replaced with each diaper change.
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? A. Radiation B. Convection C. Conduction D. Evaporation
D. Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.
An infant is born in the breech position, and assessment indicates the presence of Erb palsy (Erb-Duchenne paralysis). Which clinical manifestation supports this conclusion? A. Inability to turn the head to the unaffected side B. Absence of the grasp reflex on the affected side C. Absence of the Moro reflex on the unaffected side D. Flaccid arm with the elbow extended on the affected side
D. Flaccid arm with the elbow extended on the affected side With Erb-Duchenne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. The grasp reflex is intact, because the fingers usually are not affected; if C8 is injured, paralysis of the hand results (Klumpke paralysis). There would be an absence of the Moro reflex only on the affected side. There is no interference with head turning; usually injury results from excessive lateral flexion of the head as the shoulder is delivered.
A newborn has just begun to breast-feed for the first time. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse best intervene at this time? A. Tell the client to use the other breast and continue breast-feeding B. Delay the feeding to allow more time for the infant to recover from the birthing process C. Contact the lactation consultant to help the client learn a more successful breast-feeding technique D. Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula
D. Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breast-feeding techniques.
Which action should the nurse promote to enhance a neonate's behavioral development? A. Keep the infant awake for longer periods of time before each feeding. B. Touch and talk to the infant hourly, starting at least 3 hours after birth. C. Encourage parental contact with the baby for 15 minutes every 4 hours. D. Help the parents stimulate their awake baby through touch, sound, and sight.
D. Help the parents stimulate their awake baby through touch, sound, and sight. Stimuli are provided by way of all the senses; because the infant's behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged. Infants require interactions soon after birth and consistently thereafter, but interactions should occur during the infant's regular waking periods.
A nurse performing a newborn assessment elicits the Babinski reflex. What does the nurse conclude that this finding indicates? A. Hypoxia during labor B. Neurological injury during birth C. Hyperreflexia of the muscular system D. Immaturity of the central nervous system (CNS)
D. Immaturity of the central nervous system (CNS) Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. The newborn would not elicit the Babinski reflex if there were neurological injury during birth. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.
What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? A. Average for gestational age, term B. Small for gestational age, preterm C. Large for gestational age, postterm D. Large for gestational age, near term
D. Large for gestational age, near term Newborns of diabetic mothers may be large for gestational age because hyperglycemia in the mother precipitates hyperinsulinism in the fetus, resulting in excess deposits of fetal fat; these infants are usually born at or before term and are large, not average or small, for gestational age. Diabetic mothers with advanced vascular and renal disease may give birth to infants who are small for gestational age. Because of the risk for fetal death, women with diabetes should give birth before the 40th week of gestation, either by way of induction of labor or, if necessary, by cesarean birth.
What should the nurse discuss with new parents to assist them in preparing for infant care? A. Allowing crying time to help the lungs develop B. Establishing a set feeding schedule to promote steady weight gain C. Counting the number of stool diapers daily to confirm adequate hydration D. Learning specific behaviors involving states of wakefulness to promote positive interactions
D. Learning specific behaviors involving states of wakefulness to promote positive interactions Discussing behaviors during the baby's waking times that will promote positive interaction helps parents understand the unique features of their newborn and promotes interaction and care during periods of wakefulness. A healthy infant's lungs are developed at birth. It is best that infants be on a demand feeding schedule, not a routine schedule. Demand feeding provides for individuality; healthy infants gain weight steadily. Counting the number of stool diapers daily is not a reliable method of determining adequate hydration.
The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to what? A. Early rooming-in B. Taking-in behaviors C. Taking-hold behaviors D. Parent-child attachment
D. Parent-child attachment There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychologic behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychologic behavior described by Rubin that occurs after the third postpartum day.
A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery? A. Stimulating crying B. Administering oxygen C. Putting a moist saline dressing on the cord stump D. Providing for suctioning of the oropharynx as the head emerges
D. Providing for suctioning of the oropharynx as the head emerges The color of the amniotic fluid is indicative of meconium staining; the practitioner must therefore prepare for the potential for fetal aspiration of meconium. The newborn should not be stimulated to cry until the airway has been cleared of meconium. Oxygen is administered only after a patent airway is established and if needed. Putting a moist saline dressing on the cord stump is unnecessary, because there is no indication that umbilical cord blood or a transfusion is needed.
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. Which complication do these adjustments attempt to prevent? A. Cataracts B. Strabismus C. Ophthalmia neonatorum D. Retinopathy of prematurity
D. Retinopathy of prematurity Retinopathy of prematurity is caused by the high concentration of oxygen that may have to be used to support some preterm neonates; oxygen must be administered cautiously and, depending on the neonate's blood oxygen level, adjusted accordingly. Cataracts and strabismus (crossed eyes) are not caused by a high oxygen concentration. Ophthalmia neonatorum refers to an inflammation of the eyes caused by a gonorrheal or chlamydial infection contracted as the fetus passes through the birth canal.
The first-time parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding? A. They are obstructed sebaceous glands. B. They are excessive superficial capillaries. C. The cause is a decreased vitamin K level in the newborn. D. The cause is an increased intravascular pressure during birth.
D. The cause is an increased intravascular pressure during birth. Pressure exerted during the birth process causes increased intravascular pressure, which may result in petechiae caused by capillary rupture. Obstructed sebaceous glands are milia, which are white, not red. Superficial capillaries are intact capillaries. They are distinguished from petechiae if they disappear when the area is blanched. Bloody stools or oozing from the umbilicus is the most common sign of vitamin K deficiency, not red pinpoint dots on an infant's face and neck.
A male newborn has been exposed to human immunodeficiency virus (HIV) in utero. Which assessment supports the diagnosis of HIV infection in the newborn? A. Delay in temperature regulation B. Continued bleeding after circumcision C. Hypoglycemia within the first day of birth D. Thrush that does not respond readily to treatment
D. Thrush that does not respond readily to treatment Thrush, an oral infection caused by Candida albicans, is an opportunistic infection that may be indicative of underlying HIV infection. A delay in temperature regulation is more commonly associated with immaturity of the hypothalamus. Bleeding after a circumcision is associated with a bleeding disorder such as hemophilia. Hypoglycemia is usually associated with the infant of a diabetic mother.
A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit. When should the nurse take the neonate's mother to visit the infant? A. When the infant's condition has stabilized B. When the infant is out of immediate danger C. When the primary healthcare provider has provided written permission D. When the mother is well enough to be taken to the intensive care unit
D. When the mother is well enough to be taken to the intensive care unit The mother should see her infant as soon as possible so that she may acknowledge the reality of the birth and begin bonding. A delay impedes maternal-infant bonding. A prescription is not needed, because this is an independent nursing action. The infant's condition is not a controlling factor in determining when the mother initially visits.
