Prep U ch 24

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply. expiratory grunting nasal flaring retractions tachypnea bradypnea

expiratory grunting nasal flaring retractions tachypnea

While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this client? Select all that apply. grunting nasal flaring intercostal retractions oxygen saturation 96% increasing respiratory rate

grunting nasal flaring intercostal retractions increasing respiratory rate

A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess? head larger than body round flushed face brown lanugo body hair protuberant abdomen

head larger than body

The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first? Seizure Respiratory distress Cardiovascular distress Hypoglycemia

Respiratory distress

The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate? The infant was a preterm, low-birth-weight and small-for-gestational-age neonate. The infant was born at term but at a low-birth-weight and small-for-gestational- age. The infant was born at term but a very-low-birth-weight and small-for-gestational-age. The infant was a preterm, very-low-birth-weight and small-for-gestational-age.

The infant was a preterm, low-birth-weight and small-for-gestational-age neonate.

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment? The newborn may look wrinkled and old at birth. The infant may have excess of lanugo and vernix caseosa. The testes in the child may be undescended. The newborn may have short nails and hair.

The newborn may look wrinkled and old at birth.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? an infant whose labor began with ruptured membranes an infant who had difficulty establishing respirations at birth an infant who has marked acrocyanosis of his hands and feet an infant whose mother craved chocolate during pregnancy

an infant who had difficulty establishing respirations at birth

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

breast milk

A nurse is explaining to the mother of a premature newborn about the need to help maintain the neonate's body temperature. Which of the following would the nurse integrate into the teaching about why this newborn may have difficulty regulating his body temperature? Select all that apply. less brown fat more flaccid posture larger body surface area greater total body water-to-weight ratio looser skin

less brown fat more flaccid posture larger body surface area

Following resuscitation, an infant weighing 1,814 g (4 lb) is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment? stabilized respiratory effort absence of apnea stabilized cardiac function presence of bowel sounds

stabilized respiratory effort

The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant? to detect rebound hypoglycemia to determine insulin dosage to administer to explain the effects of maternal hyperglycemia on the baby to estimate the amount of calories to provide the infant through formula

to detect rebound hypoglycemia

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? "You are lucky to have given birth to a term newborn." "We still need to monitor him closely for problems." "How do you feel about giving birth to your baby at 36 weeks?" "Your baby is premature and needs monitoring in the NICU."

"We still need to monitor him closely for problems."

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response? "You can give your baby a sucrose solution by bottle for pain relief." "Offer your baby a feeding of sterile water solution by bottle." "The fussiness will go away shortly with tight swaddling." "Your baby is not feeling pain but irritated with all the handling."

"You can give your baby a sucrose solution by bottle for pain relief."

A newborn is exhibiting signs and symptoms of hypoglycemia. The nurse prepares to administer IV glucose based on which blood glucose level? 36 mg/dl (2.0 mmol/L) 45 mg/dl (2.5 mmol/L) 50 mg/dl (2.77 mmol/L) 55 mg/dl (3.05 mmol/L)

36 mg/dl (2.0 mmol/L)

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Closely monitor temperature. Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance.

Closely monitor temperature.

After a rapid assessment determines that a newborn is in need of resuscitation, the nurse would perform which action first? Dry the newborn thoroughly. Suction the airway. Administer ventilations. Give volume expanders.

Dry the newborn thoroughly.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? Deep inspiration Expiratory lag Sternal retraction Inspiratory grunt

Sternal retraction

What is a typical feature of a small-for-gestational-age (SGA) newborn that differentiates it from a preterm baby with a low-birth-weight? decreased muscle mass face is angular and pinched decreased body temperature ability to tolerate early oral feeding

ability to tolerate early oral feeding

The nurse places a newborn experiencing respiratory difficulty under a radiant warmer to prevent which complication? acidosis alkalosis hypoxia hypercapnia

acidosis

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? shivering hyperglycemia apnea metabolic alkalosis

apnea

A client has given birth to a full-term infant weighing 10 pounds, 5 ounces (4678 grams). What priority assessment should be completed by the nurse? blood glucose temperature control feeding difficulty perfusion

blood glucose

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. diabetes postdates gestation alcohol use prepregnancy obesity renal infection

diabetes postdates gestation prepregnancy obesity

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? assists with ciliary body maturation in the upper airways helps maintain a rhythmic breathing pattern promotes clearing of mucus from the respiratory tract helps the lungs remain expanded after the initiation of breathing

helps the lungs remain expanded after the initiation of breathing

What is a consequence of hypothermia in a newborn? respirations of 46 heart rate of 126 holds breath 25 seconds skin pink and warm

holds breath 25 seconds

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature? meconium aspiration absence of lanugo hypoglycemia increased amounts of vernix

increased amounts of vernix

The nurse is caring for a 6-month-old infant who is the probable victim of abusive head trauma (shaken baby syndrome). The nurse is completing the baseline neurologic assessment. Which assessment finding requires health care provider notification because it is a sign of early increased intracranial pressure? spitting up a mouthful of formula pupils reactive to light and accommodation positive Babinski sign irritability

irritability

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding? lack of body posturing sudden high-pitched cry increased muscle tone fussiness

lack of body posturing

A newborn is designated as very-low-birth-weight. When weighing this newborn, the nurse would expect to find which weight? less than 1,500 g more than 4,000 g approximately 2,500 g less than 1,000 g

less than 1,500 g

A nurse is assessing a newborn who is about 8 hours old. The nurse suspects that the newborn may be experiencing cold stress based on which finding(s)? Select all that apply. lethargy hypotonia jaundice hypoglycemia tachypnea

lethargy hypotonia tachypnea

A nurse is conducting a class for expectant parents about newborns. As part of the class, the nurse describes newborns with birth weight variations. The nurse determines that the teaching was successful when the class identifies which variation if a newborn weighs 5.2 lb (2,358 g) at any gestational age? small-for-gestational-age low-birth-weight very-low-birth-weight extremely-low-birth-weight

low-birth-weight

If the nurse suspects intraventricular hemorrhage (IVH) in a preterm newborn, which of the following would the nurse be likely to find? no signs or only subtle signs restlessness, crying, irritability redness and bruising on the scalp tachycardia and hyperperfusion

no signs or only subtle signs

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply. obtain hemoglobin and hematocrit laboratory tests provide early feedings to prevent hypoglycemia maintain oxygen saturation parameters monitor urinary output insert a peripheral IV

obtain hemoglobin and hematocrit laboratory tests provide early feedings to prevent hypoglycemia maintain oxygen saturation parameters monitor urinary output

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant? placental factors blood group incompatibility grand multiparity age of 30 years

placental factors

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

polycythemia

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period? anemia probably due to chronic fetal hypoxia hyperthermia due to decreased glycogen stores hyperglycemia due to decreased glycogen stores polycythemia, probably due to chronic fetal hypoxia

polycythemia, probably due to chronic fetal hypoxia

The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). strong cry heart rate of 142 beats/min poor feeding elevated temperature

poor feeding

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition? respiratory distress syndrome Down syndrome hydrocephalus esophageal atresia

respiratory distress syndrome

In the neonatal intensive care unit (NICU), the nurse is assessing an infant born at 28 weeks' gestation. What finding(s) alert the nurse that the infant is beginning to develop respiratory distress syndrome? Select all that apply. respiratory rate of 70 breaths/min dimished breath sounds in all lung fields nasal flaring cyanotic mucus membranes sternal retractions

respiratory rate of 70 breaths/min nasal flaring sternal retractions

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration? bronchopulmonary dysplasia (chronic lung disease) retinopathy of prematurity diminished erythropoiesis necrotizing enterocolitis

retinopathy of prematurity

A nurse is assessing a newborn and notifies the primary health care provider because the nurse suspects increased intracranial pressure. When reporting the findings, which of the following would the nurse most likely include? soft, nonbulging fontanels (fontanelles) overriding sutures seizure activity vital signs within acceptable ranges

seizure activity

A nurse is preparing a presentation for a group of perinatal nurses about common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the nurse includes which factor as contributing to the newborn's risk? Select all that apply. surfactant deficiency placental deprivation immaturity of the respiratory control centers decreased amounts of brown fat depleted glycogen stores

surfactant deficiency immaturity of the respiratory control centers

The nurse is teaching gavage feedings to the mother of a preterm infant. Which instruction is most important? Amount of feeding Expelling of gas Gastric residual present Quantity of bowel movement

Gastric residual present

A pregnant client with diabetes is preparing for the birth of a large-for-gestational-age newborn. What intervention(s) will the nurse include in the initial postbirth plan of care for the newborn? Select all that apply. Provide thermoregulation. Maintain blood glucose. Assess respiratory status. Collect bilirubin levels. Initiate a peripheral IV.

Provide thermoregulation. Maintain blood glucose. Assess respiratory status.

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant? Dry the infant, stimulate the infant, and keep the infant warm. Dry the infant, administer blow-by oxygen, and keep the infant warm. Open the airway, initiate respirations, and dry the infant. Open the airway, suction the trachea, and administer oxygen.

Dry the infant, stimulate the infant, and keep the infant warm.

When an infant is jaundiced, what is the nurse's main role in treatment? Educate the caregiver. Comfort the infant. Feed the infant. Draw blood for analysis.

Educate the caregiver.

A large-for-gestational age newborn has a blood glucose level of 30 mg/dl and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next? Encourage frequent feedings. Feed the newborn 2 ounces of dextrose water. Initiate blow-by oxygen therapy. Place the newborn under a radiant warmer.

Encourage frequent feedings.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. It takes energy to keep warm, so the neonate has to remain in an extended position. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress.

If the neonate becomes cold stressed, he or she will eventually develop respiratory distress.

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply. Monitor urine output. Observe for bleeding. Auscultate for bilateral breath sounds. Palpate for abdominal rigidity. Monitor blood pressure.

Monitor urine output. Observe for bleeding.

The nurse is caring for a preterm neonate on an apnea monitor. When the monitor alarms, what action does the nurse take? Select all that apply. Performs a focused assessment of the neonate Silences the alarm Administers a dose of caffeine Counts the respiratory rate for a full minute Begins bag and mask ventilation

Performs a focused assessment of the neonate Silences the alarm Counts the respiratory rate for a full minute

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which findings would support the nurse's suspicion? Select all that apply. shallow, slow respirations cyanotic hands and feet irritability hypertonicity feeble cry

shallow, slow respirations cyanotic hands and feet feeble cry