the neonate

After circumcision with a Plastibell, the nurse should instruct the neonate's parent to cleanse the circumcision site with which agent? antibacterial soap warm water povidone-iodine solution diluted hydrogen peroxide

warm water Explanation: After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and are not recommended. Povidone-iodine solution may cause stinging and burning, and therefore its use is not recommended.

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond? "They're normal and will disappear as the baby's skin thickens." "They're a common congenital abnormality." "They commonly result from a traumatic delivery." "They're caused by a blockage in the apocrine glands."

"They're normal and will disappear as the baby's skin thickens." Explanation: Capillary hemangioma (also called a "stork bite") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and will disappear as the skin thickens. They are not associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands.

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? Take the neonate's temperature immediately according to hospital policy. Do nothing — acrocyanosis is normal in the neonate. Activate the code emergency response system. Notify the physician that a cardiac consult is needed.

Do nothing — acrocyanosis is normal in the neonate. Explanation: Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. Activating the code emergency response system, taking the neonate's temperature, and notifying the physician that a cardiac consult is needed are inappropriate actions.

The nurse has completed discharge teaching with new parents who will be bottle-feeding their term newborn. Which statement by the parents reflects the need for more teaching? "The baby should burp during and after each feeding with no projective vomiting." "We should weigh our baby daily to make sure they are gaining weight." "Our baby will require feedings through the night for several weeks or months after birth." "Our baby should have one to three soft, formed stools a day."

"We should weigh our baby daily to make sure they are gaining weight." Explanation: Healthy infants are weighed during their visits to their health care provider, so it is not necessary to monitor weights at home. Infants may require one to three feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a term newborn. Bottle-fed infants may stool one to three times daily.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism? Chlamydia trachomatis Staphylococcus aureus beta-hemolytic streptococcus Escherichia coli

Chlamydia trachomatis Explanation: The use of erythromycin ophthalmic ointment prevents blindness from gonococcal organisms and C. trachomatis. This ointment usually is less expensive than tetracycline.Beta-hemolytic streptococcus, E. coli, and S. aureus can cause a generalized infection in the neonate. However, these organisms typically are not responsible for causing neonatal blindness.

A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate? Dress the neonate in loose-fitting clothing. Place the isolette close to the nurse's station. Withhold medications until liver function improves. Place the isolette in a quiet area of the nursery.

Place the isolette in a quiet area of the nursery. Explanation: The neonate experiencing drug withdrawal should be placed in a quiet area of the nursery to minimize stimuli; the nurses' station is typically not a quiet area. The neonate should be swaddled to prevent him from stimulating himself with movement. Medications should be administered as needed.

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? An iron-fortified formula will be given before surgery. The birth parent may breastfeed the neonate before surgery. The neonate will remain on nothing-by-mouth (NPO) status until after surgery. The neonate will need total parenteral nutrition for nourishment.

The neonate will remain on nothing-by-mouth (NPO) status until after surgery. Explanation: 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.

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

bronchopulmonary dysplasia Explanation: 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 client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find lethargy 2 days after birth. a flattened nose, small eyes, and thin lips. congenital defects such as limb anomalies. irritability and poor sucking.

irritability and poor sucking. Explanation: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in neonates with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode? positive Babinski's reflex jitteriness hyperalert state serum glucose level of 60 mg/dl (3.3 mmol/L)

jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl (2.2 mmol/L). A hyperalert state suggests neurologic irritability and isn't associated with blood glucose levels. A positive Babinski's reflex is a normal finding in neonates and isn't associated with hypoglycemia. A serum glucose level of 60 mg/dl (3.3 mmol/L) is a normal level.

A nurse is caring for a neonate with a suspected diaphragmatic hernia. Which order should the nurse question? immediate endotracheal intubation chest x-ray mask ventilation placement of an orogastric tube

mask ventilation Explanation: The nurse should question an order for mask ventilation because this procedure may introduce air into the neonate's GI tract. An emergency chest x-ray can help diagnose diaphragmatic hernia. An orogastric tube is appropriate because it decompresses the bowel and stomach within the neonate's chest. Intubation is needed to ventilate the neonate.

Sick and preterm neonates who experience continuity of nursing care directly benefit from nursing recognition of subtle changes in high-risk neonates' conditions. decreased hospital liability for professional malpractice. higher levels of professional satisfaction among nurses. higher levels of parent satisfaction with nursing care.

nursing recognition of subtle changes in high-risk neonates' conditions. Explanation: Continuity of care allows the nurse to observe subtle changes in a neonate's condition. Although nurses and parents experience higher levels of satisfaction and professional liability may decline, these results aren't direct benefits to the neonate.

A nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (90 mL) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find? thick upper lip upturned nose large for gestational age prominent nasal bridge

upturned nose Explanation: Neonates born with fetal alcohol syndrome have upturned noses, flattened nasal bridges, and a thin upper lip. They may also be small for gestational age.

The nurse has completed breastfeeding discharge instructions and determines the birth parent understands the instructions when they make which statement(s)? Select all that apply. "Babies should have six to eight wet diapers a day after the first 3 days of life." "I have the phone number for the lactation consultant if I have questions." "Babies should be satisfied from the feeding for 5 to 6 hours after daytime feedings." "Any drugs I take may pass through to my baby through my breast milk." "My calorie intake will need to increase by 1000 calories per day."

"Any drugs I take may pass through to my baby through my breast milk." "Babies should have six to eight wet diapers a day after the first 3 days of life." "I have the phone number for the lactation consultant if I have questions." Explanation: Maternal intake will need to increase by approximately 500 calories per day while the client is breastfeeding. It is true that many drugs taken by the birth parent cross through breast milk. When any medication is taken by the breastfeeding mom, the medication should be determined to be safe by the OB's or pediatrician's office. Infants who have six to eight wet diapers per day have had an adequate intake of breast milk. If there are fewer, the birth parent should try to increase the frequency of the infant's feedings. Within the first 24 to 72 hours of life, there will be fewer wet diapers as the parent's milk has not come in yet. Before discharge, clients should know how to access community resources to support breastfeeding. After a parent's breast milk is in at about the third day after birth, the infant should be satisfied for approximately 1½ to 3 hours after feeding. There is a need for more frequent feedings with breastfed infants than bottle-fed infants as the fat content in breast milk is lower.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate? Notify the health care provider (HCP) immediately. Document these findings as minor deviations. Explain these deviations to the newborn's mother. Ask the mother to consent to genetic studies.

Notify the health care provider (HCP) immediately. Explanation: A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the HCP immediately. The HCP should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.

A multiparous client gives birth to twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized? Discuss how they will cope with twin infants at home. Identify complications that may occur as the twins develop. Participate in the care of the twins as much as possible. Take turns providing 24-hour observation of the twins.

Participate in the care of the twins as much as possible. Explanation: It is important that the parents be allowed to touch, hold, and participate in the care of the twins whenever they desire. Ideally, this will be done on a daily basis to promote parent-infant bonding. It is not appropriate to discuss how the couple will cope with twin infants at home until they are ready to take the infants home. They are too overwhelmed at this point and are focused on the well-being of their infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not warranted. Identifying complications that may occur is not appropriate. If complications arise, the parents should be well informed and given opportunities for discussion related to the care provided.

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What action should the nurse take next? Ask the birth parent to massage the neonate's hands and feet. Place the infant skin to skin with the birth parent. Report the neonate's cyanosis to the health care provider promptly. Keep the neonate in an isolation incubator for at least 2 hours.

Place the infant skin to skin with the birth parent. Explanation: The neonate is demonstrating acrocyanosis, a normal finding evidenced by bluish hands and feet due to the neonate being cold or poor perfusion of the blood to the periphery of the body. The most appropriate action is to place the neonate skin to skin with the birth mother if stable, wrap the neonate in a warm blanket, or place the neonate under a radiant warmer.Massaging the extremities is inappropriate because it will not help to improve the circulation.Keeping the neonate in an isolation incubator is not warranted because acrocyanosis is not an infection but rather a manifestation of the neonate's sluggish peripheral circulation.Because acrocyanosis is a normal finding, notifying the health care provider is not necessary.

When teaching a primiparous client who used cocaine during pregnancy how to comfort their fussy neonate, the nurse can advise the client to use which intervention? Tightly swaddle the neonate. Keep the neonate in a brightly lit environment. Feed the neonate extra, high-calorie formula. Touch the baby only when they are crying.

Tightly swaddle the neonate. Explanation: A neonate undergoing cocaine withdrawal is irritable, often restless, difficult to console, and often in need of increased activity. It is commonly helpful to swaddle the neonate tightly with a blanket, offer a pacifier, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastrointestinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to solely when they are crying will not aid the bonding process between birth parent and neonate. Frequent holding and touching are permissible.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that caput succedaneum occurs primarily with primigravidas. a cephalohematoma occurs with a birth that required instrumentation. a cephalohematoma doesn't cross the suture lines. caput succedaneum occurs primarily with a prolonged second stage of labor.

a cephalohematoma doesn't cross the suture lines. Explanation: Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the neonate's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

The nurse reviews the daily weights of a breastfeeding term newborn. The nurse's best action is to: notify the health care provider. reweigh the newborn. continue routine monitoring. provide supplementation.

continue routine monitoring. Explanation: Up to a 10% weight loss in the first few days of life is normal in a breastfeeding newborn. This newborn's weight loss is under 10%, so the nurse can assume that breastfeeding is going as expected and just needs routine monitoring. There is no need to reweigh the newborn or notify the health care provider. Best breastfeeding practices do not include supplementation unless there is a medical reason.

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to enhance bonding by pointing out the neonate's features. question the mother about her preterm labor. explain the NICU visiting policy for the mother and family. obtain a family medical history.

enhance bonding by pointing out the neonate's features. Explanation: Pointing out neonate's features to the mother enables the mother to begin to bond with him. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the mother about her preterm labor don't take priority over enhancing maternal bonding.

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 best explains the main function and goal of surfactant use? promotes mucous production lubricating the respiratory tract helps maintain a rhythmic breathing pattern reducing tachypnea helps lungs remain expanded after the initiation of breathing improving oxygenation assists with ciliary body maturation in the upper airways eliminating mucous

helps lungs remain expanded after the initiation of breathing improving oxygenation Explanation: 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.

A neonate weighing 1870 g (4.1 lb) with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 (reference range 7.35 to 7.45) has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding? does not become edematous develops respiratory alkalosis is not dehydrated resolves the metabolic acidosis

resolves the metabolic acidosis Explanation: Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used.Diuretics, not sodium bicarbonate, would be used to combat edema.Intravenous fluids would be used to treat dehydration.Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to a client with alkalosis would only further exacerbate the alkalotic condition.

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? myelomeningocele spina bifida occulta spina bifida cystica meningocele

spina bifida occulta Explanation: A small tuft of hair and an indentation at the base of the neonate's spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits.

While changing her newborn's diaper, a mother states: "there is some bleeding from the vagina." Which is the nurse's appropriate response? "Your infant is dehydrated, which is why there is some bleeding in the diaper." "The wet wipes must be irritating the skin. I will call the healthcare provider." "Because the newborn's stool was runny, I doubt you can see any bleeding." "This is in response to your hormones and will stop within a week."

"This is in response to your hormones and will stop within a week." Explanation: Pseudomenstruation is caused by a withdrawal of maternal hormones within the first week of life. Suggesting dehydration does not answer the question and gives a solution without further assessment. Stating that the newborn's stool was too runny to note the blood does not validate the client's concern. Irritation to the skin is unlikely because this is usually noted on the buttocks rather than in the vagina

During neonatal resuscitation immediately after delivery, chest compressions should be initiated when the heart rate falls below 80 beats/minute. 110 beats/minute. 100 beats/minute. 60 beats/minute.

60 beats/minute. Explanation: The normal neonatal heart rate is 120 to 160 beats/minute. Heart rates lower than 60 beats/minute necessitate chest compressions and ventilatory support.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent? Change to a higher-calorie formula to prevent further weight loss. Contact the health care provider (HCP). Switch to a soy-based formula because the current one seems inadequate. Continue feeding every 3 to 4 hours since the weight loss is normal.

Continue feeding every 3 to 4 hours since the weight loss is normal. Explanation: This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle feeding, the neonate's intake varies from one feeding to another. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the HCP should be called.

Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. Prior to resuscitation, the nurse would place the neonate's head in what position? Hyperextend the neonate's neck. Maintain the neonate's head in a neutral position. Keep the neonate's head in the "sniff" position. Turn the neonate's head slightly to one side.

Keep the neonate's head in the "sniff" position. Explanation: To open the airway, the nurse must keep the neonate's head in the "sniff" position by extending the neck slightly. Hyperextending the neck will block the infant's airway. Keeping the head in a neutral position does not open the airway fully. Turning the head to one side closes the airway and will not allow optimal ventilation.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); the baby is breathing room air and is pink with acrocyanosis. The birth parent had membranes that were ruptured 26 hours before birth. What nursing action is most indicated? Arrange a transfer to the neonatal intensive care unit with a diagnosis of possible sepsis. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. Place a pulse oximeter, and request a prescription to draw blood cultures. Draw a complete blood count (CBC) with differential, and feed the infant.

Place a pulse oximeter, and request a prescription to draw blood cultures. Explanation: The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate higher than 60 breaths/min, grunting, and occasional flaring are not normal. Although these findings are not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

Parents of a neonate who is 32 weeks of age ask the nurse, "Why does he have a feeding tube in his nose?" What is the nurse's best response? There is no sucking reflex at this gestational age. The stomach cannot digest formula or breast milk at this time. The sucking, swallowing, and breathing are not coordinated. The infant needs extra fluids to prevent dehydration.

The sucking, swallowing, and breathing are not coordinated. Explanation: At 32 weeks' gestation, a neonate has limited ability to coordinate sucking, swallowing, and breathing. The sucking reflex is present at 32 weeks' gestation, but the neonate cannot coordinate the reflex with swallowing and breathing. The stomach has the capacity for digestion at this gestational age. There are no indications that this neonate is dehydrated

A small-for-gestational-age infant is born with facial abnormalities and vision abnormalities. These abnormalities are likely caused by which maternal factor? rubella exposure folic acid deficiency alcohol consumption tetracycline use

alcohol consumption Explanation: Fetal alcohol syndrome is characterized by central nervous system damage, poor growth, and specific facial stigmata. As many as 90% of children with fetal alcohol syndrome have eye abnormalities. Congenital syphilis is more frequently associated with preterm birth, and tetracycline use is associated with dental abnormalities. Folic acid deficiency contributes to neural tube defects.

While caring for a female term neonate just born, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? Potter syndrome ambiguous genitalia Turner syndrome renal disorders

ambiguous genitalia Explanation: An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present.Renal disorders are associated with the absence of a kidney and oliguria.Potter syndrome is a fatal condition involving renal agenesis and facial deformities.Turner syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.

A primiparous client has just given birth to a term infant. Which topic should the nurse teach the client about first? breastfeeding/chestfeeding newborn medications sudden unexplained infant death syndrome (SUIDS) infant sleep-wake cycles

breastfeeding/chestfeeding Explanation: Ideally, breastfeeding/chestfeeding should begin immediately after birth while infants are still very awake. Successful breastfeeding/chestfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SUIDS and sleep-wake cycles are also important topics for the new parent, but this information can be given at any time prior to discharge. Newborn medications, including vitamin K and eye ointments, are given soon after birth and can be given after the first breastfeeding/chestfeeding session.

The nurse develops a teaching plan for the parent of an infant about introducing solid foods into the diet. The nurse should expect to include which measure in the plan to help prevent obesity? thin cereal with juice during the first several months introducing the infant to the taste of vegetables by mixing them with formula or breast milk decreasing the amount of formula or breast milk intake as solid food intake increases mixing cereal and fruit in a bottle when offering solid food for the first few times

decreasing the amount of formula or breast milk intake as solid food intake increases Explanation: Decreasing the amount of formula given as the infant begins to take solids helps prevent excess caloric intake. Because the infant is receiving calories from solid foods, the formula no longer needs to provide the infant's total caloric requirements. Mixing vegetables with formula or breast milk does not allow the child to become accustomed to new textures or tastes. Solid foods should be given with a spoon, not in a bottle. Using a bottle with food allows the infant to ingest more food than is needed. Juice has very little nutritional value compared with formula or breastmilk and contributes to obesity. The nurse should advise parents not to give juice to children under the age of 1 year. After 1 year of age, juice intake should be limited to 1 serving or less a day

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal? hypothermia high-pitched cry bradycardia sluggishness

high-pitched cry Explanation: Manifestations of opiate withdrawal in the neonate, known as neonatal abstinence syndrome (NAS), include increased central nervous system irritability, which can manifest as a high-pitched cry. Sluggishness or lethargy are not symptoms of NAS. Metabolic, vasomotor, and respiratory disturbances seen with NAS involve tachycardia and fever, not bradycardia or fever. These signs usually appear within 72 hours and persist for several days.

A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant? hypoglycemia failure to thrive passage of meconium jaundice

hypoglycemia Explanation: A large-for-gestational-age infant is at risk for hypoglycemia due to the possibility of a birth parent having diabetes (may or may not be diagnosed or related to gestation). The fetus makes insulin in response to the blood glucose that crosses the placenta; after birth, the fetus continues to make insulin even though high maternal blood glucose is no longer present. The result is neonatal hypoglycemia.The nurse will continue to monitor for passage of meconium in the newborn, but it may take several hours and is not a priority at this time.While nurses assess amniotic fluid for meconium so they can suction the airway at birth and attempt to prevent meconium aspiration of the newborn, this infant is already at least 5 minutes of age and breathing (according to the Apgar scores). The infant may develop jaundice or failure to thrive, but there is no information to suggest these findings at this time.

.The nurse prepares to obtain a neonatal screening test for phenylketonuria (PKU). The nurse understands that the neonate must have been fed what to ensure reliable results? iron-rich formula initial formula or breast milk at least 24 hours before the test nothing by mouth for 4 hours before the test glucose water

initial formula or breast milk at least 24 hours before the test Explanation: PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid phenylalanine to tyrosine. To ensure reliable results, the neonate must have ingested sufficient protein, such as breast milk or formula, for at least 24 hours. Testing the infant before that time, excessive vomiting, or poor intake can yield false-negative results. The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.

Which finding is considered normal in the neonate during the first few days after birth? weight gain of 25% birth weight of 4½ to 5½ lb (2,000 to 2,500 g) weight loss of 25% weight loss then return to birth weight

weight loss then return to birth weight Explanation: Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's birth parent, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The parent asks the nurse if the neonate is positive for HIV. The nurse can tell the parent which information? "A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." "An enlarged liver at birth generally means the neonate is HIV positive." "More than 50% of neonates born to birth parents who are positive for HIV will be positive at 18 months of age." "We will test your baby now, but testing will need to be repeated for an accurate diagnosis."

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis." Explanation: New recommendations state that virologic diagnostic testing at birth should be considered for infants at high risk for HIV infection, but it may take several months before an accurate diagnosis can be made. New guidelines suggest that infants should be tested at 2 to 3 weeks, at 1 to 2 months, and at 4 to 6 months. It is estimated that 15% to 30% of all HIV-positive birth parents without treatment will give birth to HIV-positive infants. With appropriate drug intervention for the parent during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infection. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonucleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the first month.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? Excessive weight gain Urine specific gravity below 1.012 Bulging fontanels Urine output below 1 ml/hour

Urine output below 1 ml/hour Explanation: Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed, not bulging, fontanels; excessive weight loss, not gain; decreased skin turgor; dry mucous membranes; and urine specific gravity above, not below, 1.012.

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents? a neonate who's mildly depressed a neonate who's moderately depressed a neonate who's in good condition a neonate who needs additional oxygen to improve the Apgar score

a neonate who's in good condition Explanation: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

Which action is the best precaution against transmission of infection? strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection strict isolation for a neonate whose mother has human immunodeficiency virus (HIV)

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Explanation: Mothers can transmit gonorrhea during the birth process; untreated, it can cause serious eye damage to the neonate. A neonate whose mother has hepatitis B should receive hepatitis B immunoglobulin within 12 hours of birth, not eye prophylaxis. CMV doesn't require strict isolation; however, the neonate may be treated with I.V. antivirals. HIV is transmitted via blood and body fluids. Contact isolation, not strict isolation, is appropriate.

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

hypoglycemia Explanation: 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.

Two hours ago, a neonate at 38 weeks' gestation and weighing 3175 g (3.18 kg) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)? temperature instability positive Babinski reflex increased muscle tone alkalosis

temperature instability Explanation: The neonate is at high risk for sepsis due to exposure to the birth parent's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vomiting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respiratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski reflex is a normal finding and does not need to be reported.

The nurse assesses a postterm neonate. Which finding is considered normal for a postterm infant? wrinkled, peeling skin flattened nose small hands and feet red abdominal rash

wrinkled, peeling skin Explanation: A common finding for postmature neonates is wrinkled, peeling skin. A flattened nose is associated with neonates who have trisomy 21, not with a postmature neonate. Small hands and feet are typically found in preterm and small-for-gestational-age neonates, not in a postterm neonate.There is no relationship between postmaturity and a red abdominal rash. An abdominal rash may be seen in any newborn in the first few days of life.

A nurse is attempting to resuscitate a neonate. Thirty seconds of chest compressions have been completed. The neonate's heart rate remains less than 60 bpm. Epinephrine is given. What is the expected outcome for a neonate who has received epinephrine during resuscitation? sedation pain relief a normal heart rate increased urine output

a normal heart rate Explanation: Epinephrine is given for severe bradycardia and hypotension. An expected outcome would be an increased heart rate to a normal range. Epinephrine decreases renal blood flow, so a decrease in urine output would be expected. Epinephrine also stimulates alpha- and beta-adrenergic receptors, which do not offer pain relief or sedation.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? hypospadias phimosis epispadias hydrocele

hypospadias Explanation: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder exstrophy.

The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt and are exhibiting anxiety about how the neonate will be treated. Which action by the nurse would be most appropriate initially? Suggest that they make an appointment to talk things over with a counselor. Arrange a meeting with other parents whose infants have had successful clubfoot treatment. Ask them to share these concerns with the health care provider (HCP). Discuss the problem with the parents and the current feelings that they are experiencing.

Discuss the problem with the parents and the current feelings that they are experiencing. Explanation: When an infant is born with an unexpected anomaly, parents are faced with questions, uncertainties, and possible disappointments. They may feel inadequate, helpless, and anxious. The nurse can help the parents initially by assessing their concerns and providing appropriate information to help them clarify or resolve the immediate problems. Referring the parents to the HCP is not necessary at this time. The nurse can assist the parents by listening to their concerns. Having them talk with other parents would be helpful a little bit later once the nurse assesses their concerns and discusses the problem and the parents' current feelings. If the parents continue to have difficulties expressing and working through their feelings, referral to a counselor would be appropriate.

The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? Formula supplements can provide nutrients not found in breast milk. Water supplements should be primarily used to prevent jaundice. More vigorous sucking is needed for bottle-feeding, so supplements should be avoided. Formula feeding should be avoided to prevent interfering with the breast milk supply.

Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established.Bottle supplements are not appropriate to prevent jaundice, though if the neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding.Breastfeeding is considered the best nutritional source for infants.Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner? Humidify the air being delivered. Cover the neonate's scalp with a warm cap. Record the neonate's temperature every 3 to 4 minutes. Assess the neonate's blood glucose level.

Humidify the air being delivered. Explanation: Whenever oxygen is administered, it should be humidified to prevent drying of the nasal passages and mucous membranes. Because the neonate is under a radiant warmer, a stocking cap is not necessary. Temperature, continuously monitored by a skin probe attached to the radiant warmer, is recorded every 30 to 60 minutes initially. Although the oxygen concentration in the hood requires close monitoring and measurement of blood gases, checking the blood glucose level is not necessary.

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate's Apgar score is 5 at 1 minute. What is the nurse's most important intervention for this premature neonate? Assess the vital signs. Stimulate the neonate to cry. Warm the neonate. Administer oxygen.

Administer oxygen. Explanation: The preterm neonate lacks surfactant. Surfactant lowers the surface tension in the alveoli and stabilizes them to prevent their collapse. Even if the premature neonate can initiate respirations, there is limited ability to retain air due to insufficient surfactant. This leads to hypoxemia and hypoxia. Therefore, it is most essential for the nurse to make sure the head is in the sniff position and oxygen is administered. The neonate should be evaluated for respiratory distress and poor respiratory effort. In most premature births, a neonatologist or pediatrician is in the delivery room. The premature neonate born at 28 weeks' gestation would most likely be intubated and ventilated shortly after birth, but oxygen needs to continue to be delivered until intubation occurs. The neonate also needs to be kept warm because cold stress leads to respiratory distress. A premature neonate born at 28 weeks' gestation would automatically have poor tone and reflexes from the premature development; this is a neonate who should not be stimulated. The vital signs are important, but they are not as important as initiating and maintaining respirations.

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? Notify the physician immediately. Ask the physician for an order to obtain cultures of both of the neonate's eyes. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. Obtain a nasal viral culture.

Ask the physician for an order to obtain cultures of both of the neonate's eyes. Explanation: 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.

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 normal response that occurs during the transition from intrauterine to extrauterine life interrupted supply of maternal glucose and continued high neonatal insulin production increased pancreatic enzyme production caused by decreased glucose stores increased use of glucose stores during a difficult labor and birth process

interrupted supply of maternal glucose and continued high neonatal insulin production Explanation: 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.

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? appropriate dose of Rho(D) immune globulin presence of maternal antibodies degree of anemia in the neonate initial bilirubin level

presence of maternal antibodies Explanation: 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.

The nurse teaches the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly. The nurse determines that the teaching was successful when the parent describes the condition in which way? "The lower bowel is lacking certain nerves to allow normal function." "The muscle below the stomach is too tight, causing the baby to vomit forcefully." "A part of the bowel is on the outside without anything covering it." "There is a blind upper pouch and an opening from the esophagus into the airway."

"There is a blind upper pouch and an opening from the esophagus into the airway." Explanation: Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.

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

Continue monitoring because these spots are normal. Explanation: 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.

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? Risk for aspiration related to nil orally status. Deficient knowledge related to inability to cope. Deficient knowledge related to lack of exposure to apnea monitor. Deficient knowledge related to ventilatory support.

Deficient knowledge related to lack of exposure to apnea monitor. Explanation: 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.

The nurse is caring for a neonate diagnosed with early-onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents' teaching plan? Visit but do not touch the neonate. Wear protective gear near the isolation incubator. Wash hands thoroughly before touching the neonate. Wear a mask when holding the neonate.

Wash hands thoroughly before touching the neonate. Explanation: The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. It is not necessary for parents to wear protective gear near the isolation incubator. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. The baby will not spread sepsis via respiratory droplets to the parents, so it is not necessary for the parents to wear a mask.

A nurse is teaching a client who gave birth to a full-term female neonate how to change the neonate's diaper. Which of the following statement by the client would indicate to the nurse that learning has taken place? "I will fold a cloth diaper so that a double thickness covers the front." "I will position the neonate so that urine will fall to the back of the diaper." "I will clean and dry the neonate's perineal area from front to back." "I will place a disposable diaper over a cloth diaper to provide extra protection."

"I will clean and dry the neonate's perineal area from front to back." Explanation: When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.

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? first period of reactivity a state of deep sleep respiratory distress drug withdrawal

a state of deep sleep Explanation: 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.

A nurse notices that a newborn has a swelling in the scrotal area. The nurse interprets this swelling as indicative of hydrocele if what else occurs? The swollen bulge can be reduced. The increase in scrotal size is bilateral. The bulge appears during crying. The scrotal sac can be transilluminated.

The scrotal sac can be transilluminated. Explanation: A hydrocele, defined as fluid in the processus vaginalis, is determined when the scrotal sac can be transilluminated. A swelling in the scrotal area that can be reduced indicates an inguinal hernia. Both hydroceles and hernias can enlarge the scrotal sac, and both can be either unilateral or bilateral. A hernia typically is more obvious during crying.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched? Stimulate the neonate to cry to obtain information to document. Request that the health care provider evaluate the neonate's neurologic status. Tell the birth parent that excessive analgesia in labor can cause this type of cry. Continue to monitor the infant periodically for changes in the cry.

Request that the health care provider evaluate the neonate's neurologic status. Explanation: Typically a neonate's cry is loud and lusty. A weak, shrill, or high-pitched cry is not normal, possibly indicating a neurologic problem, such as increased intracranial pressure, infection, or hypoglycemia. Thus, the nurse should request that the health care provider evaluate the neonate.Telling the birth mother that the cry is due to excessive analgesia in labor is not warranted. Stimulating the neonate to cry is not helpful because the cry is most likely due to an underlying problem.Continuing to monitor the infant is a routine nursing responsibility that may be helpful if the neonate needs to be treated for a neurologic problem or drug withdrawal. However, the health care provider needs to be notified first.

When assessing a neonate 1 hour after birth, the nurse observes that the neonate exhibits slight cyanosis when quiet but becomes pink when crying. The nurse is unable to pass a catheter through the left nostril. The nurse notifies the health care provider because the neonate most likely is exhibiting signs and symptoms of which problem? unilateral choanal atresia respiratory distress syndrome tracheoesophageal fistula esophageal reflux disorder

unilateral choanal atresia Explanation: Infants are obligatory nose breathers except when crying. The observation that the infant has slight cyanosis when quiet but becomes pink when crying and the inability to pass a catheter through the left nostril suggest that the neonate is exhibiting symptoms of unilateral choanal atresia. With this condition, one of the nasal passages is blocked by an abnormality of the septum. Surgical intervention is necessary to open the nostril.Typically, a neonate with esophageal reflux disorder exhibits episodes of apnea and vomiting after eating.Respiratory distress syndrome commonly occurs in preterm neonates who lack surfactant to maintain lung expansion. Common findings include sternal retractions, tachypnea, grunting respirations, nasal flaring, cyanosis, pallor, hypotonia, and bradycardia.A neonate with tracheoesophageal fistula commonly exhibits cyanosis during feedings and vomiting.

A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which interventions will the nurse include in the infant's plan of care? Select all that apply. Monitor for temperature instability. Ensure that the first bowel movement is within the first 12 hours. Assess for signs of respiratory distress. Plan for an early discharge home with mother. Watch for apnea lasting longer than 20 seconds.

Monitor for temperature instability. Watch for apnea lasting longer than 20 seconds. Assess for signs of respiratory distress. Explanation: GBS can be transmitted from the mother to newborn during birth; this can result in the newborn developing septicemia. The newborn will be kept 24-48 hours to monitor for development of a GBS infection. Signs of GBS infection are similar to respiratory distress accompanied by temperature instability. Apnea lasting 20 seconds or longer may also indicate infection. The first bowel movement is unrelated to GBS infection.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis? "Support the neonate's head and back with the forearm." "Use one hand to support the neonate's head." "Strap the neonate into the bath basin." "Hold the neonate loosely and gently."

"Support the neonate's head and back with the forearm." Explanation: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

A neonate was admitted to the pediatric unit with an unexpected congenital defect. What is the best way to involve the parents in the neonate's care? Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. Tell the parents that they'll be shown one time how to do everything for the neonate before they take him home. Assume the parents have already been told how to care for their neonate. Don't show the parents how to care for the neonate at this time.

Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. Explanation: Many new parents need to grieve over the loss of a "normal" child. Therefore, adequate time and support should be given for the parents to adjust to the unexpected condition of their child. Never assume that the parents have already been educated about the neonate's care, or that they'll be able to learn everything they need to know after receiving instructions only once. The parents should be involved in the neonate's care during hospitalization because this involvement will help them learn and will instill confidence.

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: the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. the neonate latches onto the areola and swallows audibly. the neonate voids once or twice every 24 hours. the neonate breast-feeds four times in 24 hours.

the neonate latches onto the areola and swallows audibly. Explanation: 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 neonate. Which assessment finding would be normal for a neonate? let-down reflex "sunset" eyes doll's eyes positive Babinski's reflex

positive Babinski's reflex Explanation: A positive Babinski's reflex is present in neonates and infants until approximately age 1. However, this reflex is abnormal in adults. Doll's eyes are a neurologic response noted in adults. The appearance of "sunset" eyes, in which the sclera is visible above the iris, results from cranial nerve palsies and may indicate increased intracranial pressure. A neonate's pupils normally react to light in the same way as an adult's.

Which assessment finding in a term neonate would cause the nurse to notify the health care provider (HCP)? absence of tears red circle on pupils seen with a penlight pupillary constriction to bright light unequally sized corneas

unequally sized corneas Explanation: Corneas of unequal size should be reported because this may indicate congenital glaucoma. An absence of tears is common because the neonate's lacrimal glands are not yet functioning. The neonate's pupils normally constrict when a bright light is focused on them. The finding implies that light perception and visual acuity are present, as they should be after birth. A red circle on the pupils is seen when a penlight or ophthalmoscope's light shines onto the retina and is a normal finding. Called the red reflex, this indicates that the light is shining onto the retina.

What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? Apply gentle pressure to the site with a sterile gauze pad. Notify the neonate's health care provider immediately. Check the diaper and circumcision again in 30 minutes. Secure the diaper tightly to apply pressure on the site.

Apply gentle pressure to the site with a sterile gauze pad. Explanation: If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.The health care provider needs to be notified when bleeding cannot be stopped by conservative measures because this may signal a clotting disorder.Typically the neonate's circumcision site, including the diaper, is examined every 15 minutes for 1 hour to assess bleeding. Rechecking in 30 minutes may be too late if the neonate is actively bleeding.Securing the diaper tightly to apply pressure does not allow the nurse to observe whether the bleeding has stoppe

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

recommending the use of analgesia for circumcision Explanation: 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.

After instructing a parent about normal reflexes of term neonates, the nurse determines that the parent understands the instructions when they describe the tonic neck reflex as occurring when the neonate displays which behavior? pulls both arms and does not move the chin beyond the point of the elbows steps briskly when held upright near a firm, hard surface turns head to the left, extends the left extremities, and flexes the right extremities extends and abducts the arms and legs with the toes fanning open

turns head to the left, extends the left extremities, and flexes the right extremities Explanation: The tonic neck reflex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and flexes the right extremities. This reflex disappears in a matter of months as the neonatal nervous system matures. The stepping reflex is demonstrated when the infant is held upright near a hard, firm surface. The prone crawl reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski reflex.

The nurse is teaching the parent of a newborn to develop their baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the parent to perform which action? Give infant formula with a sweetened taste to stimulate feeding. Speak in a high-pitched voice to get the newborn's attention. Place the newborn about 12 inches (30.5 cm) from the maternal face for best sight. Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple.

Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple. Explanation: Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn the eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.

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? The meatus can become stenosed, leading to urinary obstruction. The infant's penis is too small to safely circumcise. The associated chordee is difficult to remove during circumcision. The foreskin is used to repair the deformity surgically.

The foreskin is used to repair the deformity surgically. Explanation: 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.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended because the neonate needs increased fat in the diet. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Explanation: Many intensive care units that care for high-risk neonates recommend that the birth parent pump their breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is not recommended because the neonate needs increased fat in the diet. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Explanation: Many intensive care units that care for high-risk neonates recommend that the birth parent pump their breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan? Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal. Term neonates generally have few creases on the soles of their feet. Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. If erythema toxicum is present, it will be treated with antibiotic therapy.

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Explanation: Milia are white papules resulting from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Parents should be instructed to avoid scratching them to prevent secondary infection. Term neonates generally have many creases on the soles of their feet. Preterm neonates may have only a few creases due to their immaturity. Strawberry hemangiomas are elevated areas formed by immature capillaries that will disappear over time. Port wine stains are deep, dark red discolorations that require laser therapy for removal. Erythema toxicum is a newborn rash or "flea bite" rash that requires no treatment and disappears over time.

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? Notify the parents to bring the neonate to the hospital to repeat the test. Notify the blood bank because the neonate requires a blood transfusion. Notify the healthcare provider of the normal test result. Notify the healthcare provider because the test result is critically elevated.

Notify the healthcare provider because the test result is critically elevated. Explanation: 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.

The nurse is assessing the newborn's reflexes. During assessment of the rooting reflex, the newborn turns the head opposite of the cheek being stroked. What priority action should the nurse take? Inform the newborn's parents. Document as a normal reflex. Notify the healthcare provider. Reassess the reflex in 1 hour.

Notify the healthcare provider. Explanation: The newborn's reflexes are assessed to evaluate neurological function and development. Absent or abnormal reflexes in a newborn, persistence of a reflex past the age when the reflex normally disappears, or the return of an infantile reflex indicates neurologic pathology. The rooting reflex is elicited by stroking the newborn's cheek or stroking near the corner of the newborn's mouth. The newborn normally turns the head in the direction of the stroking, looking for food. This reflex disappears by 4 to 6 months. Because turning away from the stimulus is an abnormal finding, the nurse should notify the healthcare provider and document the finding as abnormal. The newborn should be reassessed for this reflex but not in any specific time frame. The nurse would discuss the finding with the healthcare provider first to determine the significance of the finding and then plan for further assessment. This should be done before alarming the parents with information that could be unimportant.

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? PKU is carried on recessive genes contributed by each parent. PKU will not impact future childbearing for the family. PKU is caused by a recessive gene contributed by either parent. PKU is cured by eliminating dietary protein for this child.

PKU is carried on recessive genes contributed by each parent. Explanation: 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.

While caring for a client and their 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains the neonate's need for gavage feeding at this time instead of the client's plan for bottle-feeding. What should the nurse include as the rationale for this feeding plan? The neonate has difficulty coordinating sucking, swallowing, and breathing. This type of feeding, easily given in the isolette, decreases the neonate's risk for cold stress. A high-calorie formula, presently needed at this time, is more easily delivered via gavage. Gavage feedings can minimize the neonate's increased risk for developing hypoglycemia.

The neonate has difficulty coordinating sucking, swallowing, and breathing. Explanation: Before 32 weeks' gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle-feeding. Bottle-feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feeding prevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment.