PassPoint The Neonate ML8

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of A. standard infant formula. B. sterile water. C. iron-fortified infant formula. D. glucose water.

C For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

On examination of a Black newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which nursing action is appropriate? A. Inform the health care provider about the condition. B. Ask the mother about any complications in pregnancy. C. Consider the finding as normal in a Black client. D. Put a dressing over the pigmented area.

C The nurse should consider the pigmented area as normal in Black newborns. These are called flat gray nevi (formerly called Mongolian spots), which are clusters of melanocytes. Asking the mother about complications in pregnancy, informing the health care provider about the condition, and putting a dressing over the pigmented area are inappropriate responses because the finding is normal.

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? A. bronchopulmonary dysplasia B. renal failure C. hydrocephalus D. esophageal atresia

A Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation.

A neonate receives an intravenous (IV) infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. A. when the infusion is started B. when the neonate moves in the crib C. at the beginning of each shift D. when the neonate returns from x-ray E. after the parents have visited

A, C, D The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? A. abundance of scalp hair B. numerous scrotal rugae C. thin, wasted appearance D. descended testicles

C The premature neonate characteristically exhibits a thin, wasted appearance and commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal, and the absence of rugae on the scrotum is typical.

Which instructions should the nurse give to the birth parent after noting a white, cheese-like substance on the neonate's body creases? A. Brush it off with a dry washcloth. B. Remove it with hand lotion. C. Clean the area with alcohol. D. Allow it to remain on the skin.

D The white, cheese-like substance on the neonate's body creases is called vernix caseosa. Unless the vernix is stained with meconium or the birth mother has a bloodborne pathogen, it should be left on the skin because it serves as a protective coating that typically disappears within 24 hours of birth.Attempting to remove vernix caseosa (e.g., with lotion, alcohol, or a washcloth) will remove the protection and may damage the neonate's fragile skin.

A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? A. arrhythmia B. hypoglycemia C. hyperglycemia D. hypertension

B Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as the neonate's body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.

While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this as which finding? A. port-wine stain B. stork bite C. café au lait spot D. newborn rash

B Several irregularly shaped red patches, common skin variations in neonates, are termed stork bites. They eventually fade away as the neonate grows older. Port-wine stains are disfiguring darkish red or purplish skin discolorations on the scalp and face that may need laser therapy for removal. Newborn rash is typically generalized over the body, not localized to one body area, and is commonly raised. Café au lait spots are brown and typically found anywhere on the body. More than six spots or spots larger than 1.5 cm are associated with neurofibromatosis, a genetic condition of neural tissue.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action bestexplains the main function and goal of surfactant use? A. helps maintain a rhythmic breathing pattern reducing tachypnea B. helps lungs remain expanded after the initiation of breathing improving oxygenation C. assists with ciliary body maturation in the upper airways eliminating mucous D. promotes mucous production lubricating the respiratory tract

B Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract.

Which characteristic should the nurse teach the birth parent about their neonate diagnosed with fetal alcohol syndrome (FAS)? A. Neonates are commonly lethargic. B. The IQ scores are usually average. C. Neurologic disorders are common. D. The mortality rate is 70% unless treated.

C Neurologic disorders are common in neonates with FAS. Speech and language disorders and hyperactivity are common manifestations of central nervous system dysfunction. Mild-to-severe intellectual disability and feeding problems also are common. Delayed growth and development are expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mortality rate, and there is no treatment for FAS, but early intervention improves client outcomes.

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be A. "Your breasts will be firm and filled with colostrum at this time." B. "Breast-feeding will inhibit prolactin production." C. "Breast-feeding will prevent the newborn from heat loss." D. "The neonate will be responsive and eager to suck at this time."

D During the first 30 minutes or so after birth, the healthy, full-term neonate is highly responsive and has a strong desire to suck. Many neonates breast-feed shortly after birth; all make licking or nuzzling motions, helping to stimulate the mother's prolactin production and enhance maternal-neonate bonding. Also, the client's breasts may be soft and easily manipulated at this time, promoting proper attachment of the neonate. Although the breasts contain colostrum at this time, they aren't firm. Typically, the neonate falls asleep 2 to 3 hours after birth.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: A. the neonate latches onto the areola and swallows audibly. B. the neonate voids once or twice every 24 hours. C. the neonate breast-feeds four times in 24 hours. D. the neonate loses 10% to 15% of the birth weight within the first 2 days after birth.

A Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. A. The neonate doesn't respond when the nurse claps her hands above him. B. The neonate grasps the nurse's finger when she puts it in the palm of the neonate's hand. C. The neonate turns toward the nurse's finger when she touches the neonate's cheek. D. The neonate does stepping movements when held upright with sole of foot touching a surface. E. The neonate's toes do not fan out when soles of the feet are stroked. F. The neonate displays weak, ineffective sucking.

A, E, F Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not flare when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the flaring of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 4,650 g (4.65 kg) and is at 41 weeks' gestation. What would be the priority problem for this neonate? A. impaired skin integrity B. risk for impaired parent-infant-child attachment C. impaired gas exchange D. hyperglycemia

C The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing an adequate respiration rate is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, risk for impaired parent-child attachment may be appropriate once the airway is established.

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy? A. ensuring that the neonate has had nothing by mouth (NPO) for at least 6 hours before the procedure B. promptly returning the neonate to his mother for comfort and bonding after the procedure C. monitoring the neonate for the excessive bleeding after the procedure D. recommending the use of analgesia for circumcision

D Recommending the use of analgesia is an example of advocacy for the neonate. Ensuring that the neonate has been NPO for at least 6 hours before the procedure, monitoring for excessive bleeding after the procedure, and returning the neonate to his mother for comfort and bonding are examples of providing safe care, not of advocacy.

When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of A. gastroesophageal reflux (GER) B. aspiration. C. suffocation. D. sudden infant death syndrome (SIDS)

D The supine position is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with supine positioning. Although suffocation is less likely if the neonate is supine, the primary intervention for reducing suffocation risk is removing blankets and pillows from the crib. The position for GER requires the head of the bed to be elevated.

A client returns to the postnatal ward with her 3-week-old infant. Which statement by the client would prompt the nurse to evaluate the infant for inadequate intake? A. "The baby does not burp after a feeding." B. "The baby wets 6 to 10 diapers in 24 hours." C. "The baby does not exhibit a steady weight gain." D. "The baby shows a desire to be fed every 3 to 4 hours."

C Newborns differ in their feeding needs and preferences. Most breastfed babies need to be fed every 2-3 hours, nursing for 10-20 minutes on each breast. Formula-fed babies usually feed every 3-4 hours, finishing a bottle in 30 minutes or less. Weight gain is the best measure of the infant receiving adequate nutrition. If the newborn seems satisfied, wets 6-10 diapers per day, produces several stools a day, sleeps well, and is gaining weight regularly, then the baby is receiving adequate fluid intake and nutrition. Newborns swallow air during feeding, which can cause fussiness and discomfort. They should be burped several times throughout the feeding. The amount of burping does not relate to weight gain.

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth? A. fluctuating blood glucose results B. fluctuating body temperature C. respiratory distress D. peripheral and circumoral cyanosis

C One of the most crucial adaptations the newborn makes at birth is adjusting from a fluid-filled intrauterine environment to a gaseous extrauterine environment. The fluid from the intrauterine life environment must be removed so the infant can breathe. Passage through the birth canal allows intermittent compression of the thorax, which helps eliminate the fluid. If a mother has a cesarean birth, this compression does not occur, and transient tachypnea (respiratory rate above 60) can develop. Unstable blood sugars, poor thermoregulation, and peripheral and circumoral cyanosis (acrocyanosis) are associated with all newborns and not necessarily related to cesarean delivery.

A family has taken home their newborn and later received a call from the child's health care provider (HCP) that the phenylketonuria (PKU) levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. What information should the nurse tell the parents about the disease? A. PKU is caused by a recessive gene contributed by either parent. B. PKU will not impact future childbearing for the family. C. PKU is carried on recessive genes contributed by each parent. D. PKU is cured by eliminating dietary protein for this child.

C Phenylketonuria is a disease that is carried on the recessive genes of each parent. In order to be transmitted to a newborn, the infant inherits a recessive gene from each parent. Control of the disease is by reduction of the amino acid phenylalanine, which is present in all protein foods. The disease cannot be cured, but controlled. With each pregnancy, there is a 25% chance a child will inherit the disease.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding? A. Keep the neonate on nothing-by-mouth status and observe for seizures. B. Call the physician and inform him of the finding. C. Tell the parents this is a normal finding for a neonate who was breech. D. Note the finding on the assessment record.

D Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture line and typically clears within a few days after birth. The nurse should note this finding on the assessment record, but no other action is needed. Caput succedaneum isn't found on neonates who were in the breech position.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? A. respiratory distress B. first period of reactivity C. a state of deep sleep D. drug withdrawal

C At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress in this scenario because the neonate's respiratory rate of 35 breaths/min is normal.

The nurse is notified that a neonate who was discharged several days ago has a phenylketonuria (PKU) metabolic screening test result of 7 mg/dL. What action should the nurse take? A. Notify the parents to bring the neonate to the hospital to repeat the test. B. Notify the healthcare provider of the normal test result. C. Notify the healthcare provider because the test result is critically elevated. D. Notify the blood bank because the neonate requires a blood transfusion.

C A normal test result for PKU metabolic screening is < 2 mg/dL; a level of 7 mg/dL is critically elevated. The nurse should immediately notify the healthcare provider who should then notify the parents and ask them to bring the neonate to the facility for immediate evaluation. The neonate should have a definitive serum test performed and should be evaluated by a pediatrician who specializes in inborn errors of metabolism such as PKU. Early intervention prevents intellectual disability that can occur as a result of PKU. The test does not need to be repeated prior to contacting the healthcare provider. Blood transfusions are not indicated for PKU.

A primigravid client in early labor tells the nurse that she was exposed to rubella at about 14 weeks' gestation. After birth, the nurse should assess the neonate for which complication? A. cardiac disorders B. renal disorders C. hydrocephaly D. bulging fontanels

A Pregnant women who become infected with the rubella virus early in pregnancy risk having a neonate born with rubella syndrome. The symptoms include thrombocytopenia, cataracts, cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive neonatal effects occur when the mother is exposed during the first 2 to 6 weeks and up to 12 weeks' gestation, when critical organs are forming. Bulging fontanels are associated with increased intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal infection.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first? A. Raise the neonate's head and pat the back gently. B. Clear the neonate's airway with suction or gravity. C. Start mouth-to-mouth resuscitation. D. Contact the neonatal resuscitation team.

B If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction.Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway.Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway.Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged, causing further breathing difficulties.

A neonate born by cesarean birth at 42 weeks' gestation, weighing 4100 g (4.1 kg), with Apgar scores of 8 at 1 minute after birth and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours after birth. What is the priorityproblem for this neonate? A. decreased cardiac output B. hypoglycemia C. ineffective airway clearance D. hyperthermia

B Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the post-term neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the post-term neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean birth, which is not considered a difficult birth.

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material has which characteristic? A. a brownish color B. usually occurring before a feeding C. a curdled appearance D. one-time occurrence during feeding

C Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and it occurs during or immediately after feeding.Vomiting is unrelated to feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 ml.Vomited material is typically white and curdled in appearance. A brownish color suggests old blood.Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.

A neonate receives an Apgar score of 6 at 5 minutes of age. What additional assessment will the nurse prioritize for this 5-minute Apgar score? A. oxygen saturation B. respiratory rate C. temperature D. heart rate

A Apgar scores at 1 minute gives the nurse an indication of the neonate's adaptation to extrauterine life. At 5 minutes, a clearer picture of the neonate's overall central nervous system status is obtained. When a neonate has a score between 4 and 6, the neonate is having some difficulty. A score of 6 or below indicates there is respiratory difficulty, so the nurse should assess the oxygen saturation to determine the level of need for supplemental oxygen therapy and to provide a baseline upon which to determine response to treatment. Heart rate and respiratory rate are already incorporated in the Apgar assessment. Body temperature can affect Apgar score and hypothermia needs to be addressed, but oxygen saturation takes priority.

The parent of a neonate diagnosed with gastroschisis tells the nurse that their spouse had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate? A. The neonate will need total parenteral nutrition for nourishment. B. The birth parent may breastfeed the neonate before surgery. C. The neonate will remain on nothing-by-mouth (NPO) status until after surgery. D. An iron-fortified formula will be given before surgery.

C The parents need to know that the neonate will be kept on NPO status and will receive intravenous therapy before surgery. After surgery, feeding will depend on the neonate's condition. Total parenteral nutrition may be prescribed after surgery, but not before. Breastfeeding may be started after surgery if the neonate's condition is stable. The birth parent can pump the breasts until that time.

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first? A. Obtain blood cultures. B. Give a 10 mL/kg bolus of fluid. C. Place a urinary bag for drug screening. D. Start ampicillin 125 mg IV now.

A All of the orders that the health care provider initiated are important but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable.

The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. What nursing action should the nurse take next? A. Take the neonate's blood pressure in all four extremities. B. Call for a cardiac consult. C. Note and tell the health care provider (HCP) when rounds are made. D. Place the neonate in reverse Trendelenburg position.

A The next nursing action in this situation would be to assess the blood pressure in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency, and the HCP needs to be notified as soon as the blood pressure data have been collected. Generally, prescribing an HCP consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities.

A parent is visiting their neonate in the neonatal intensive care unit. The baby is fussy and the parent wants to know what to do. To quiet a sick neonate, what can the nurse teach the parent to do? A. Use a constant, gentle touch. B. Stroke the neonate's back. C. Place a musical mobile over the crib. D. Bring in toys for distraction.

A Neonates who are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.

The parents of a neonate with hypospadias and chordee wish to have them circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? A. The foreskin is used to repair the deformity surgically. B. The infant's penis is too small to safely circumcise. C. The associated chordee is difficult to remove during circumcision. D. The meatus can become stenosed, leading to urinary obstruction.

A The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The reason for delaying circumcision is related to correcting the position of the meatus and is not related to penis size.

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the parent visits the neonate at 1 hour after birth, the nurse explains to the parent that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? A. increased use of glucose stores during a difficult labor and birth process B. increased pancreatic enzyme production caused by decreased glucose stores C. interrupted supply of maternal glucose and continued high neonatal insulin production D. a normal response that occurs during the transition from intrauterine to extrauterine life

C Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually 30 to 60 minutes after birth. Most neonates do not develop hypoglycemia if their birth parents are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? A. hyperabduction and extension of the arms with external rotation of the hips B. abduction and flexion of the arms with flattened shoulders C. adduction and flexion of the extremities with gently rounded shoulders D. neck extension and back arching with flattened shoulders

C The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? A. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. B. Obtain a nasal viral culture. C. Ask the physician for an order to obtain cultures of both of the neonate's eyes. D. Notify the physician immediately.

C Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus.

A nurse has been teaching a new mother how to feed her infant who was born with a cleft lip and palate. Which action by the mother indicates that the teaching has been successful? A. placing the baby flat during feedings B. burping the baby frequently C. providing fluids with a small spoon D. placing the nipple in the cleft palate

B Because an infant with a cleft lip and palate can not grasp a nipple securely, the infant may swallow a large amount of air during feedings and, therefore, require frequent burping. An infant with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons shouldn't be used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? A. Deficient knowledge related to ventilatory support. B. Deficient knowledge related to lack of exposure to apnea monitor. C. Deficient knowledge related to inability to cope. D. Risk for aspiration related to nil orally status.

B For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after birth but would probably be resolved by the time the neonate is ready for discharge.

Which action would be most appropriate for a neonate whose hemoglobin is 16 g/dL (160 g/L) immediately after birth? A. Assess for skin pallor and anemia. B. Document this as a normal finding. C. Assess for symptoms of polycythemia. D. Recheck the hemoglobin in 1 hour.

B Normal neonatal hemoglobin level ranges from 15 to 20 g/dL (150 to 200 g/L) blood. After birth, the hemoglobin level gradually decreases. The nurse should document this as a normal finding.The neonate does not demonstrate symptoms of polycythemia, such as red, ruddy skin color, a hematocrit level greater than 65% (0.65), or a hemoglobin level greater than 20 g/dL (200 g/L).Because the hemoglobin value is within normal parameters, there is no need for the nurse to recheck the hemoglobin in an hour.The hemoglobin level is within normal parameters. If it was decreased, then assessing for skin pallor and anemia would be warranted.

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance? A. somatotropin B. progesterone C. surfactant D. testosterone

C RDS, previously called hyaline membrane disease, is a developmental condition involving a decrease in lung surfactant that leads to improper expansion of the lung alveoli. Surfactant contains a group of surface-active phospholipids, of which one component—lecithin—is the most critical for alveolar stability. Surfactant production peaks at about 35 weeks' gestation. This syndrome primarily attacks preterm neonates, though it can also affect term and postterm neonates. Altered somatotropin secretion is associated with growth disorders such as gigantism or dwarfism. Altered testosterone secretion is associated with masculinization. Altered progesterone secretion is associated with spontaneous abortion during pregnancy.

Which action is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment? A. Try to remove the specks with a wet washcloth. B. Place the neonate in an isolation area. C. Continue monitoring because these spots are normal. D. Attempt to obtain a sterile specimen on a swab.

C Small, shiny white specks on the neonate's gums and hard palate are known as Epstein pearls. They have no special significance and often disappear within a few weeks. However, white patches on the inside of the mouth, possibly signaling thrush due to Candida albicans infection, warrant further investigation.Isolation is not necessary because this finding is normal and the neonate is not contagious.Because these specks often disappear within a few weeks, the nurse does not need to remove these with a wet washcloth.Sending a sterile specimen to the laboratory is not necessary because this finding is normal.

The nurse is preparing to administer vitamin K to a 1-hour-old newborn. Which newborn would have the highest potential for hemorrhage? A. born to a mother who has type 2 diabetes and is breastfeeding B. has an axillary temperature of 97.7°F (36.5°C) and is being formula-fed C. born to a mother who took phenytoin during pregnancy and is breastfeeding D. sustained caput succedaneum during birth and is formula-fed

C Vitamin K is a fat-soluble vitamin that promotes the synthesis of prothrombin by the liver. Newborns are at risk for vitamin K deficiency (and, therefore, for bleeding) because the newborn's gastrointestinal tract is sterile. Vitamin K is not produced until after microorganisms are produced, typically about a week after feedings have started. All newborns receive a vitamin K injection prophylactically shortly after birth. The nurse should be concerned about the neonate whose mother took the anticonvulsant phenytoin during pregnancy and is breastfeeding. This drug inhibits the production of vitamin K so the mother would have no/very low levels of vitamin K. Additionally, vitamin K levels are very low in breast milk, so without supplementation of vitamin K the infant would be at highest risk for hemorrhage. The other infants have fewer risk factors. Caput succedaneum is edema and presents no risk for bleeding. An axillary temperature of 97.7°F (36.5°C) is within the normal range for a newborn.

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan? A. hypothermia related to immature temperature regulation B. imbalanced nutrition: less than body requirements related to inadequate feeding C. risk for injury related to hyperbilirubinemia D. deficient fluid volume related to insensible fluid loss

C Yellow sclerae indicate bilirubin deposits and possible hyperbilirubinemia. The nurse should add a diagnosis of risk for injury related to hyperbilirubinemia to the care plan because bilirubinemia may cause bilirubin encephalopathy (kernicterus). The assessment findings don't support a nursing diagnosis of imbalanced nutrition: less than body requirements related to inadequate feeding because neonates normally breast-feed every 2 to 3 hours. An axillary temperature of 98° F (36.7° C) is within normal limits for a neonate, eliminating hypothermia as a nursing diagnosis. Loss of up to 10% of birth weight is normal in neonates, making a diagnosis of deficient fluid volume inappropriate.

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using one decimal place.

240 45mL*8 = 360mL/30 = 12*20 = 240 cal

The nurse is caring for a neonate who has a suspected neonatal sepsis. The healthcare provider's order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record your answer using a whole number.

85 100mg/kg/day*3.4kg = 340 mg/day/4 = 85mg/dose

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a parent with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? A. degree of anemia in the neonate B. appropriate dose of Rho(D) immune globulin C. initial bilirubin level D. presence of maternal antibodies

D A direct Coombs test is also known as a direct antiglobulin test (DAT). The test is done on umbilical cord blood to detect maternal antibodies coating the neonate's red blood cells. Rho(D) immune globulin doses are determined by the amount of Rh-positive neonatal blood found in the birth parent after birth. Hematocrit is used to detect anemia. A direct Coombs test does not measure bilirubin but may help explain the underlying cause of increased bilirubin levels.