Unit 2 Maternal Health

The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: "Circumcision

"Can sometimes cause complications. What questions do you have?" Rat:(Asking this question allows the nurse to determine what the questions or concerns are and address them specifically.)

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the cultural background of the family. What statement is best?

"Could you explain what your preferences are regarding childbearing?" Rat:(Sensitive, nonjudgmental exploration of the family's cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.)

Parents have been told their child has fetal alcohol syndrome. Which statement indicates that additional teaching is required?

"Cuddling and rocking will help him stay calm." Rationale 4: FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm.

The nurse is teaching an early-parenting class to families expecting their first child soon. A patient asks the nurse if breast milk is really better than formula. The best response by the nurse is:

"Formula attempts to imitate the composition of breast milk. " Rat:(This statement best answers the question about whether breast milk or formula is best. Breast milk is the "gold standard" on which formula is based. Formula attempts to provide nutrition that is similar to breast milk; however, breast milk composition is different in many ways.)

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful?

"Giving the baby his first bath can really give me a chance to get to know him." Rat:(When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior.)

The nurse is observing a couple interacting with their 2-day-old child. Which of the mother's statements suggests a potentially abnormal finding in the newborn?

"Her belly looks so round." Rat:(Abdominal distention is the first sign of many gastrointestinal abnormalities)

The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information?

"How the straps go around the baby isn't that important." Rat:(Car seats for infants are mandatory in most states. Straps must be snug around the baby in order to be effective in protecting the baby in case of a crash.)

During a post conference, nursing students are simulating physical assessment of the newborn using a model. Throughout the simulated assessment, students describe each of their actions. Which nursing student's statement indicates the need for further teaching?

"I obtained the infant's heart rate by observing the cardiac monitor." Rat:(Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.)

The nurse is completing the discharge teaching of a young first-time mother. Which statement requires immediate intervention?

"I will put my baby to bed with his bottle so he doesn't get hungry during the night." Rat:Putting a baby to bed with a propped bottle is a choking hazard and should never be done.

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education?

"Incredibly, his stomach capacity is already a cupful when he was born." Rat:(A newborn's stomach capacity is only 20-40 ml; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying)

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" The best reply is:

"Newborns have immature immune function at birth, and illness is very hard to detect." Rat:(The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn)

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or less. Which statement should the nurse include?

"The baby will respond to you the most if you look directly into your baby's eyes and talk to him." Rat:(Holding the baby en face and speaking softly obtains the most response from the baby, including eye contact, smiling, and vocalization)

The home care nurse is examining a 3-day-old infant. The skin on the child's sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. The best response from the nurse is:

"The liver of an infant is not fully mature and doesn't conjugate the bilirubin for excretion." Rat:(Physiologic jaundice is a common occurrence and peaks on day 3 or 4.)

During a community health class, the nurse is educating prenatal patients and their partners about normal newborn behavior. Which attendee's statement indicates that teaching was effective? "I can expect that my newborn baby:

"Will be able to hear very well immediately after she is born." Rat:(Newborns have very acute hearing immediately after birth.)

At birth, an infant weighed 8 pounds, 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds, 15 ounces. What explanation should the nurse give for the change in this newborn's weight? "His weight loss is:

"Within normal limits." Rat:(This newborn's weight loss is within normal limits. During the first 5-10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5-10% in term newborns.)

The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse if induction is really necessary. What response by the nurse is best?

1. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." 2. "When infants are born two or more weeks after their due date, they have meconium in the amniotic fluid." Rationale 1: This statement is correct. Rationale 2: Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome

Which statements by a breastfeeding class participant indicate that teaching was effective? Standard Text: Select all that apply.

1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfed infants have fewer digestive and respiratory illnesses." Rationale 1: This is a true statement. Rationale 2: Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation. Rationale 5: This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections.

The nurse is planning an educational session for maternal-child health unit nurses to cross-train them for providing home-based care after discharge. Which statements indicate that additional teaching is required? "The behavioral assessment:

1. "Should be done as soon after birth as possible." 2. "Can be performed without input from parents." Rat:(Rationale 1: The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth. Rationale 2: Parental input is required to fully understand the infant's behaviors that are not observed by the healthcare team)

Which of the following actions must a nurse perform before weighing the newborn during the admission procedure? Standard Text: Select all that apply.

1. Clean the scale 2. Take the infant's temperature 3. Cover the scale 4. Zero the scale Rat:(Rationale 1: This action should be performed to prevent cross infection. Rationale 2: This action should be performed to monitor heat loss. Rationale 3: This action should be performed to prevent cross infection. Rationale 4: This action should be performed to ensure an accurate measurement.)

The nurse is caring for a newborn born to a drug-addicted mother. Which of the following assessment findings would be common for this newborn? Standard Text: Select all that apply.

1. Hyperirritability 3. Exaggerated reflexes 5. Transient tachypnea Global Rationale: Newborns born to drug-addicted mothers exhibit hyperirritability, exaggerated reflexes, and transient tachypnea.

When reviewing laboratory results for a 1-day-old infant, the nurse notes that the infant's IgM antibodies are elevated. Which is the least likely cause of the infant's IgM antibody level elevation?

1. Maternal-fetal transfer of IgM while in utero Rat:(Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation. Elevated levels of IgM at birth may indicate placental leaks or, more commonly, antigenic stimulation in utero.)

A 42-year-old mother was diagnosed with placenta previa, and her baby was delivered by cesarean section at 32 weeks. At birth, the infant has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which of the following interventions are needed? Standard Text: Select all that apply.

1. Monitor the infant's cardiac and respiratory status. 4. Start the infant on iron supplements. 5. Have O-negative packed red cells ready for a transfusion. Rationale 1: This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment. Rationale 4: Iron supplements should be given to help increase red blood cell production. Rationale 5: Patients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and crossmatched packed red cells should be used.

The nurse tells the mother that the doctor is preparing to circumcise her newborn. The mother verbalizes concern that the infant will be uncomfortable during the procedure. The nurse explains to the mother that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure can include: Standard Text: Select all that apply.

1. Non-nutritive sucking. 2. Stroking the head. 4. Talking to the baby. Rat:(Rationale 1: This is an accepted method of soothing during the circumcision. Rationale 2: This is an accepted method of soothing during the circumcision. Rationale 4: This is an accepted method of soothing during the circumcision.

A change in skin color requires further assessment of which of the following physiological functions? Standard Text: Select all that apply

1. Oxygenation 2. Bilirubin levels 3. Glucose levels 4. Hematocrit Rat:(Global Rationale: Changes in skin color may indicate the need for closer assessment of temperature, cardiopulmonary status, hematocrit, glucose, and bilirubin.

Which of the following should be considered potentially infectious when providing nursing care for a newborn with an HIV-positive mother? Standard Text: Select all that apply.

1. Soiled linens 2. Urine 3. Blood 5. Feces Global Rationale: Body fluids such as blood, urine, and feces are considered potentially infectious. Therefore, soiled linens are also potentially infectious. A mask is not routinely used when caring for an infant exposed to HIV and will likely not be contaminated if used.

The nurse expects an initial weight loss for the average postpartum patient to be:

10-12 pounds. Rationale 2: 10-12 pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.

The nurse is reviewing charts of newborns. Which infant requires immediate intervention?

12-hour-old preterm female exhibiting icterus and lethargy Rat:(Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice)

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?

2-week-old infant who doesn't make eye contact when talked to Rat:(This is an abnormal finding. Infants who do not make eye contact when talked to could have an ophthalmic abnormality. )

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Standard Text: Select all that apply.

2. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 3. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 4. "If the baby's body temperature gets too low, he will warm himself up without any shivering." 5. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." Rat:(Rationale 2: Drying a wet baby prevents evaporation, one mechanism of heat loss. Rationale 3: Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. Rationale 4: Non-shivering thermogenesis is the mechanism used by newborns to warm themselves. Rationale 5: A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress.

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been found to have the condition. Which statement indicates that teaching was effective?

2. "We must be very careful to avoid most proteins to prevent brain damage." Rationale 2: PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. High phenylalanine levels cause brain damage and severe neurologic abnormalities.

An infant was born at 31-weeks' gestation and weighed 1430 g. What is the correct initial feeding regimen for this infant?

20 mg/kg/day of premature formula 24 kcal/oz. Rationale 2: This is the correct initial feeding regimen for preterm infants with a birth weight between 1251 and 1500 g

The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Standard Text: Select all that apply.

3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for two days." Rationale 3: Preterm infants grow more slowly than do term infants. Rationale 4: Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. Rationale 5: Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine.

The nurse is caring for pregnant patients. Which of these clients should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?

37-year-old G8 P2323, works in a chemical factory Rationale 1: This patient is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.

The nurse is discussing development and play activities with the parent of a 2-month-old boy. Recommendations should include giving him his first rattle at about what age?

4 months Rat:( It is recommended that a brightly colored toy/rattle be given to the child at age 4 months. Grasping has begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a noise.)

A new mother wants to be discharged with her newborn as soon as possible. Before discharge, the nurse should make certain that:

Appointment is made for home or primary care practitioner visit within next 2 to 3 days. Rat: (The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours of a short stay in either a primary practitioner's office or the home.)

A nurse is conducting a breastfeeding assessment for a primipara mother. The infant has not yet learned how to latch on strongly, and the mother begins to get frustrated. In addition, the infant seems unsettled and uninterested in eating. The mother comments that she thinks her frustration is causing her milk to spoil. How should the nurse handle this statement?

Assure the mother that there is no evidence that milk composition changes based on the mother's emotional state. The infant is fussy because he can sense the mother's frustration. Rationale 2: Infants can sense the mother's emotions, so the mother should be taught relaxation techniques to reduce her frustration and enhance the feeding experience.

Which of the following information is NOT recorded as a part of the initial newborn assessment?

Blood draw for PKU screening Rat:(Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth.)

A newborn appears pale and weak, and laboratory tests reveal the infant has iron deficiency anemia. The mother asks the nurse if it would better to breastfeed her infant or feed him a formula high in iron. What should the nurse's response be?

Breastfeed, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant Global Rationale: Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible.

Parent guidelines for relieving colic in an infant include which of the following?

Change infant's position frequently. Rat:(Changing the infant's position frequently may be beneficial. The parent can walk holding the child face down and with the child's chest across the parent's arm. The parent's hand can support the child's abdomen, applying gentle pressure.)

The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to:

Document the findings. Rat:(Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.)

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit:

Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest. Rat:(All of these characteristics are indications of a preterm infant. )

A parent of an infant with colic tells the nurse, "All this baby does is scream at me; it is a constant worry." The nurse's best action is which of the following?

Encourage parent to verbalize feelings. Rat:(Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parent's anxieties.)

The nurse has received an end of shift report on the postpartum unit. Which patient should she see first?

Primip, day of delivery, fundus firm 2 cm above umbilicus Rationale 2: This patient is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.

The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurse's response should be based on the knowledge that newborns:

Experience pain with circumcision. Rat:( Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that when circumcision is performed, procedural analgesia be provided)

The nurse is assessing a 3-day-old, breast-fed newborn who weighed 7 lb 8 oz at birth. The infant's mother is now very concerned that the infant weighs 6 lb 15 oz. The most appropriate nursing intervention is which of the following?

Explain that this weight loss is within normal limits. Rat:(The neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the tenth day of life.)

A nursing intervention to promote parent-infant attachment would be which of the following?

Explaining individual differences among infants to the parents Rat: (Nurses can positively influence the attachment of parent and child by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each child.)

The nurse is teaching a class on breast feeding to expectant parents. Select all of the following that are contraindications for breast-feeding.

Human immunodeficiency virus (HIV) in mother Maternal cancer therapy Rat: (Both of these conditions place the infant at risk. HIV can be transmitted through breast milk, as can be the metabolites of chemotherapy.)

What information should the nurse give a mother regarding the introduction of solid foods during infancy?

Foods should be introduced one at a time, at intervals of 4 to 7 days. Rat:(One food item is introduced at intervals of 4 to 7 days to allow the identification of food allergies.)

Early this morning, a baby boy was circumcised by using the Plastibell method. The nurse should tell the mother that the baby can be discharged after:

Infant voids. Rat:(The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these observations and voiding, the infant can be discharged.)

One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex II infection. The expected care for her neonate includes:

Intravenous acyclovir (Zovirax) and contact precautions. Rationale 2: These are appropriate cares for an infant at risk for developing herpes simplex II infection.

Which of the following statements best represents the first stage of the first period of reactivity in the neonate?

Is an excellent time to acquaint the parents with the infant Rat:(During the first period of reactivity, the infant is very alert, cries vigorously, may suck the fist greedily, and appears very interested in the environment. The neonate's eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and child to see each other.)

Which of the following vitamins is administered prophylactically to all newborns to ensure adequate blood clotting?

K Rat:( Vitamin K is a catalyst for the production of prothrombin and the liver clotting factors II, VII, IX, and X.)

A 38-week newborn is found to be small for gestational age. Which of the following nursing interventions should be included in the care of this newborn?

Maintain a warm environment Rationale 4: Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss.

Successful breast-feeding is most dependent on which of the following?

Mother's desire to breast-feed Rat: (The factors that contribute to successful breast feeding are the mother's desire to breast-feed, satisfaction with breast-feeding, and available support systems.)

The nurse is caring for a newborn in the special care nursery. The infant is positioned prone and has hydrocephalus. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with:

Myelomeningocele. Rationale 4: Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present.

A healthy, stable, preterm infant will soon be discharged. The nurse should recommend which of the following positions for sleep?

Non-prone Rat:(The American Academy of Pediatrics recommends that healthy infants should be placed to sleep in a non-prone position. The non-prone position is strongly recommended for sleep

A 3-month-old infant, born at 38 weeks' gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as:

Normal development. Rat:(This is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary.)

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?

Pauses in respiration lasting 30 seconds Rat:(Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention.)

A mother called the maternity ward four days after the birth of her baby girl. She tells the nurse that she has noticed her infant's skin tone is yellow and asks if she should bring the infant to the hospital. What is the most likely cause of the infant's skin tone?

Physiologic jaundice Rationale 3: Most infants will develop physiologic jaundice 4-5 days after birth as a result of a shortened red blood cell lifespan, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding

The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing action would be appropriate?

Place a gloved finger in the newborn's mouth. Rat:(: To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth.)

The nurse is planning the care of a 1-day-old infant. Which of the following nursing interventions would protect the newborn from heat loss by convection?

Placing the newborn away from air currents Rat:(Placing the newborn away from air currents reduces heat loss by convection.

Small-for-gestational-age infants often have complications at birth, but they may also experience long-term complications. The long-term effect that is most likely to occur in SGA infants is:

Poor fine motor coordination Rationale 2: SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss.

Nursing interventions to maintain a patent airway in a neonate should include which of the following?

Positioning neonate supine after feedings Rat: (This is the position recommended by the American Academy of Pediatrics to prevent sudden infant death syndrome.)

The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to conserve the neonate's body heat by preventing heat loss through which of the following methods?

Radiation Rat:(Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the walls of the incubator and subsequently the body of the newborn.

The clinic is lending a federally approved car seat to an infant's family. The nurse should explain that the safest place to put the car seat is:

Rear facing in back seat. Rat:( The rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck. The middle of the back seat provides the safest position for the child.)

Latasha is a breast-fed infant being seen in the clinic for her 6-month checkup. Her mother tells the nurse that she recently began to suck her thumb. Which of the following is the best nursing intervention?

Reassure mother that this is very normal at this age. Rat:(Sucking is an infant's chief pleasure, and she may not be satisfied by bottle- or breast-feeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. Dental damage does not appear to occur unless the use of pacifier of finger persists after age 4 to 6 years.)

The nurse assesses the following in a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be:

Respirations 68/min Rat:(: Normal respiratory rate is 40-60 breaths/min. 68 could represent a less-than-expected transition.)

A telephone triage nurse gets a call from a postpartum patient who is concerned about jaundice. The patient's newborn is 37 hours old. What data should the nurse gather first?

Skin color Rat:(Yellow coloration of the skin and sclera is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice.)

The nurse is working with a new mother who delivered yesterday. The patient has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the patient understands breastfeeding?

Skin-to-skin contact creates tactile sensations that increase the sucking of newborns. Rat:(: Skin-to-skin contact creates tactile sensations that increase the sucking of newborns.)

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates that she understands how to provide care for an infant undergoing intensive phototherapy?

Urine-specific gravity is assessed each voiding. Rationale 1: This action is correct; urine concentration as indicated by raising urine-specific gravity indicates a need for additional fluids

The nurse has received a shift change report on infants born within the last four hours. Which newborn should the nurse see first?

Term male, grunting respirations Rat:(Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately.)

The nurse is ready to perform a discharge assessment for a 2-day-old male infant that has been circumcised. Which of the following findings require immediate intervention?

The infant has had a dry diaper since the circumcision procedure. Rat:: (If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow.)

The mother of a severely premature infant is being allowed to see her baby for the first time. The infant has an IV, a feeding tube, and is receiving phototherapy. He is also hooked up to cardiac and respiratory monitors. What information or instructions should the mother NOT receive before seeing her infant?

The mother should not touch her infant because the baby's skin is fragile and could be easily hurt. Rationale 1: Physical contact between the mother and infant will facilitate bonding and should be encouraged.

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?

The right arm is flaccid while the infant brings her left arm and fist upwards to the head Rat:(: Asymmetrical movement is not an expected finding and could indicate neurological abnormality. This should be reported to the physician immediately)

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. His mother had preeclampsia. His respiratory rate is 80; he is grunting and has nasal flaring. What is the most likely cause of this infant's condition?

Transient tachypnea of the newborn Rat: The infant is term and born by cesarean. He is most likely experiencing transient tachypnea of the newborn.

The nurse assesses that a newborn's skin has a ruddy appearance, and the peripheral pulses are decreased. The nurse suspects polycythemia. Which of the following lab reports might indicate polycythemia?

Venous hemoglobin level higher than 26 g/dL Rationale 1: A venous hemoglobin level higher than 26 g/dL indicates polycythemia.

The nurse is caring for an infant with abdominal contents protruding out approximately at the location of the umbilicus. What is the primary mechanism used to differentiate between omphalocele or gastroschisis?

With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. Rationale 4: This is a correct way to differentiate between omphalocele and gastroschisis.