OB

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents? 1 A reflex that is expected in the healthy newborn 2 A reflex that remains for the newborn's first year 3 An autonomic reflex indicating that the newborn is hungry 4 An autonomic reflex indicating the newborn's basic insecurity

1 A reflex that is expected in the healthy newborn This is the Moro reflex, which indicates an intact nervous system. The Moro reflex continues as long as the third to sixth month of life; if it persists there may be a neurologic disturbance. This reflex has no relationship to hunger; it is an involuntary response to environmental stimuli.

A nurse is assessing a newborn in the birthing room. What finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life? 1 Central cyanosis 2 Flexed extremities 3 Heart rate of 130 beats/min 4 Respiratory rate of 40 breaths/min

1 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 are expected in the healthy newborn. A heart rate of 130 beats/min is expected in the healthy newborn. A respiratory rate of 40 breaths/min is expected in the healthy newborn.

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action? 1 Suctioning the mouth 2 Administering oxygen 3 Notifying the practitioner 4 Inserting an endotracheal tube

1 Suctioning the mouth To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse's initial action does not clear the airway.

A newborn weighing 9 lb 14 oz has a cesarean birth because of cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. What should the nurse do after the initial physical assessment? 1 Administer oxygen by hood. 2 Determine the blood glucose level. 3 Pass a gavage tube for a formula feeding. 4 Transfer the newborn to the neonatal intensive care unit.

2 Determine the blood glucose level. The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant. There are no data that indicate a need for oxygen. Formula will not be given at this time, and there are no data that indicate a need for gavage feeding. The situation does not indicate the need for transfer of the newborn to the neonatal intensive care unit. The Apgar scores demonstrate that this infant is adapting to extrauterine life.

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? 1 Hypovolemia 2 Hypoglycemia 3 Hypercalcemia 4 Hypothyroidism

2 Hypoglycemia SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. Decreased blood pressure, pallor with cyanosis, tachycardia, retractions, lethargy, and a weak cry are signs of hypovolemia. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, AquaMEPHYTON) 1 mg. The nurse explains to the parents that this vitamin is administered to: 1 Facilitate bilirubin excretion. 2 Promote clotting of the blood. 3 Increase liver glycogen stores. 4 Stimulate growth of bowel flora.

2 Promote clotting of the blood. The newborn's intestinal tract is sterile and therefore does not have the intestinal flora that synthesize vitamin K, a precursor to prothrombin that is necessary for clotting. Bilirubin excretion is not affected by vitamin K. Glycogen stores are not affected by vitamin K. Stimulation of the growth of bowel flora is not affected by vitamin K.

During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond? 1 "The medicine protects your baby—that's why it's used." 2 "You'll have to check with your baby's doctor about this." 3 "Let's talk about why you don't want the medicine to be put into your baby's eyes." 4 "This medicine is required by law and should be administered right after the baby is born."

3 "Let's talk about why you don't want the medicine to be put into your baby's eyes." Talking about why the client doesn't want the medicine to be put into her baby's eyes provides the mother with an opportunity to express her concerns regarding prophylactic eye medication. Saying that the medicine protects the baby and that's why it's used cuts off communication and does not reflect back the mother's statement. It is the nurse's responsibility to discuss this issue with the mother. Stating that the medicine is required by law and should be administered right after the baby is born blocks communication; instillation may be delayed for an hour.

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond? 1 "Take another look. They seem fine to me." 2 "It's all right. Most babies have crossed eyes." 3 "This is expected. Your baby is trying to focus." 4 "You're right. I'll contact your health care provider."

3 "This is expected. Your baby is trying to focus." Newborns' eye movements are uncoordinated, and the eyes may appear crossed as they try to focus. As the eye muscles mature, the apparent strabismus disappears. Stating that the baby's eyes seem fine discounts the mother's concern and is demeaning. Although it is true that the baby's eyes are crossed, the mother should be given an explanation for the apparent strabismus. Telling the mother that she is right and that the health care provider must be contacted is misinformation that will increase the mother's anxiety.

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals: 1 A pH of 7.35 2 A potassium level of 4.6 mEq/L 3 An increased Paco2 of 55 mm Hg 4 An arterial O2 pressure of 80 mm Hg

3 An increased Paco2 of 55 mm Hg In respiratory acidosis the pH decreases and the carbon dioxide level increases. A pH of 7.35 is within the expected range of 7.32 to 7.49 for a neonate. A potassium level of 4.6 mEq/L is within the expected range of 3.5 to 5 mEq/L. The arterial oxygen level may or may not change with acidosis.

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond? 1 "Flat feet are more common in children than adults." 2 "That's hard to assess because the feet are so small." 3 "There may be a bone defect that needs further assessment." 4 "Infants' feet appear flat because the arch is covered with a fat pad."

4 "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 new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond? 1 "Are you disappointed in how your baby looks?" 2 "Don't worry—your baby's head will be round in a few days." 3 "Is there anyone in your family whose head shape is similar to your baby's?" 4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

4 "This often happens as the baby's head moves down the birth canal—the bones move for easier passage." The shape of the newborn's head is most likely the result of "molding." As the baby's head moves down the birth canal, the bones move for easier passage of the head through the birth canal. The mother needs information that is straightforward and understandable. Telling the client that this often happens as the baby's head moves down the birth canal is accurate information. Asking whether the mother is disappointed in her baby's appearance is an assumed reflection of the mother's feelings and does not address her concern; the nurse should recognize that the mother is disappointed and offer an explanation. Telling the mother that her baby's head will be round in a few days may add to the mother's anxiety because the reason for the infant's appearance has not been explained. It will take several days to determine whether the head is malformed. Asking whether anyone else in the client's family has a similarly shaped head may add to the mother's anxiety.

A newborn has just begun to breastfeed. 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 intervene? 1 Tell the client to use the other breast and continue breastfeeding. 2 Delay the feeding to allow more time for the infant to recover from the birthing process. 3 Contact the lactation consultant to help the client learn a more successful breastfeeding technique. 4 Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula.

4 Halt the feeding and notify the health care 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 breastfeeding techniques.