The Neonate

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next?

Notify the health care provider (HCP) immediately.

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

When developing a nursing care plan for an infant receiving phototherapy, the nurse should include what information in the plan of care? Select all that apply.

eye protection thermoregulation adequate skin exposure to phototherapy

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure?

insertion of a chest tube into the neonate

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected?

large size

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction?

"Brain damage may occur if the molding does not resolve quickly."

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision?

The foreskin is used to repair the deformity surgically.

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?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Notify the primary care provider because this may indicate a neurologic problem.

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); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.

Just after delivery, a nurse measures a neonate's axillary temperature at 94.1°F (34.5°C). What should the nurse do?

Rewarm the neonate gradually.

A neonate weighing 1,870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding?

resolves the metabolic acidosis

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

Keep the neonate's eyes completely covered.

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching?

"Whole milk is an acceptable alternative to formula once the baby is 4 months old." Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 oz (30 g)/day up to age 6 months. Iron-fortified formulas are recommended. Bottle-fed neonates may regain their birth weight by 10 to 14 days of age.

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?

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

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. What nursing intervention should the nurse implement when caring for a drug-exposed neonate?

Minimize environmental stimuli.

A woman gave birth to a term neonate a short time ago and has requests that a "special bracelet" be placed on the baby's wrist. What should the nurse do?

Apply the bracelet on the neonate's wrist as the mother requests.

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?

Notify the healthcare provider. 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 signficance of the finding and then plan for further assessment. This should be done before alarming the parents with information that could be unimportant.

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

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

hypoglycemia

The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Formula feeding should be avoided to prevent interfering with the breast milk supply.

What action should the nurse take when performing external chest compressions on a neonate born at 28 weeks' gestation?

Maintain a compression-to-ventilation ratio of 3:1.

A small-for-gestational-age infant is born with facial abnormalities and vision abnormalities. These abnormalities are likely caused by which maternal factor?

alcohol consumption

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position?

back, with the neck slightly extended

The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate?

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

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply

The neonate doesn't respond when the nurse claps her hands above him. The neonate's toes do not fan out when soles of the feet are stroked. The neonate displays weak, ineffective sucking.

A client is exclusively breastfeeding her 1-week-old infant and is concerned about her baby taking enough milk per day. The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate?

"That many wet diapers indicates your infant is adequately hydrated."

Which complication is common in neonates who receive prolonged mechanical ventilation at birth?

bronchopulmonary dysplasia

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding.

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do?

Use constant, gentle touch.

The nurse is caring for a 12-hour-old neonate born to a mother with diabetes mellitus. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, oxygen saturation is 92% on room air, and the blood glucose 30 mg/dL (1.7 mmol/L). What is the priorityintervention for the nurse to implement?

Administer glucose. Hypoglycemia is the most common metabolic disorder in infants. It is especially true for those infants born to type 1 diabetic mothers. In infants, blood glucose levels fall to a low point during the first few hours of life because the source of the maternal glucose is removed when the placenta is expelled. Hypoglycemia is defined as < 30 mg/dL (1.7 mmol/L) in the first 24 hours of life and < 45 mg/dL (2.6 mmol/L) thereafter, but this is qualified further by whether or not the infant is symptomatic. The symptoms of hypoglycemia include jitteriness, tachycardia, lethargy, cyanosis, a weak cry, and apnea. Early feeding helps prevent hypoglycemia. The treatment for hypoglycemia is a rapid-acting source of glucose. This can be given via a bottle or, if needed, an IV infusion. It is important to treat the infant early to prevent permanent neurological damage and seizures. The symptoms this infant is exhibiting are related to hypoglycemia, so correcting the blood glucose would be the priority.

The nurse observes a darkish blue pigment on the buttocks and back of a neonate of African descent. Which action is most appropriate?

Document this observation in the child's medical record. The bluish pigment on the buttocks and back of an infant of African descent is a common finding and should be documented as Mongolian spots in the child's medical record. These spots typically fade by the time the child is 5 or 6 years. Additional assessment by the care provider is not indicated. The marks are not bruises.

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?

Place the isolette in a quiet area of the nursery.

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information.

A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel.

the big one

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." 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.

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which information?

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis."

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? You Selected:

Arrange a meeting between the health care team and the parents to develop a care plan. A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.

The nurse plans the discharge of a newborn diagnosed with torticollis (wry neck). Which action should the nurse take?

Coordinate outpatient physical therapy. Physical therapy is the most important part of the child's plan of care. Most cases of torticollis respond to gentle stretching exercises, which the parents perform daily. Regular physical therapy is needed to monitor the infant's progress. Botulinum toxin injections are not approved for children under the age of 2 and would not be an appropriate first-line treatment for an infant. Surgery is only done if physical therapy is not successful after several months. The use of wedges to position children during sleep is not recommended because they increase the risk of SIDS.

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth?

Provide warm, humidified oxygen in a warm environment. Symptoms of transient tachypnea include respirations as high as 150 breaths/minute, retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm, humidified oxygen in a warm environment. The nurse should continuously monitor the neonate's respirations, color, and behaviors to allow for early detection and prompt intervention should problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress. Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the neonate diagnosed with meconium aspiration syndrome.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would mostsuggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention Explanation: Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse?

hypothermia The neonate's normal axillary temperature should range from approximately 97.7°F to 99.5°F (36.5°C to 37.5°C). A temperature of 95.5°F (35.3°C) is very low. When the temperature drops, the neonate is at risk for hypothermia, respiratory distress, and hypoglycemia. The normal respiratory rate for a newborn is 30 to 60 breaths/minute while resting. It can increase with crying, and it will increase if hypothermia develops. This neonate would have tachypnea instead of bradypnea. The normal heart rate for a newborn is 110 to 160 beats/minute, so 110 beats/minute would be a normal finding and not tachycardia. All neonates have acrocyanosis of the hands and feet in the first few hours of life; this would not indicate hypoxia.

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish tinge to the hands and feet) is normal on the first day after birth.

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which finding should be reported to the health care provider (HCP)?

neonatal central cyanosis

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions. 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.