Acute II Final: Neonatal & OB complications

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

Ranges for CBG in neonate: which is "red light" range?

>45 green 25-45 yellow <25 red light

4 important properties of physiologic jaundice

1. Does not occur in the first 24 hours of life 2. Occurs on days 2-3, often identified in clinic 3. Progresses in cephalocaudal direction 4. May cause drowsiness/ poor feeding starting a vicious cycle

•A baby is born precipitously in the ER. The nurses initial action should be to: 1. Establish an airway for the baby. 2. Ascertain the condition of the fundus 3. Quickly tie and cut the umbilical cord 4. Move mother and baby to the birthing unit

1. Establish an airway for the baby.

•The primary critical observation for Apgar scoring is the: 1. Heart rate 2. Respiratory rate 3. Presence of meconium 4. Evaluation of the Moro reflex

1. Heart rate

4 responses/interventions for hypoglycemia in neonate

1. monitor CBG 2. Minimal interventions: feeding, glucose gel 3. administer IV dextrose: maintenance fluids, bolus 4. minimize metabolic demand: warmth;)

Interventions for hypoglycemia in neonates depend on which 3 aspects?

1. risk 2. developmental ability 3. severity

•The expected respiratory rate of a neonate within 3 minutes of birth may be as high as: 1. 50 2. 60 3. 80 4. 100

2. 60

The client is 4 months pregnant and finds a lump in her breast and the biopsy is positive for stage II BC. Which Tx should the nurse anticipate? 1. A lumpectomy to be performed after the baby is born. 2. A modified radical mastectomy. 3. Radiation therapy to chest wall only. 4. Chemo only until baby is born.

2. Can't do rad/chemo which would also be required for lumpectomy. Tumor should be removed ASAP.

•While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? 1. Activate the code blue or emergency system. 2. Do nothing because acrocyanosis is normal in the neonate 3. Immediately take the newborn's temperature according to hospital policy 4. Notify the physician of the need for a cardiac consult

2. Do nothing because acrocyanosis is normal in the neonate Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

•The nurse is aware that a healthy newborns respirations are: 1. Regular, abdominal, 40-50 per minute, deep 2. Irregular, abdominal, 30-60 per minute, shallow 3. Irregular, initiated by chest wall, 30-60 per minute, deep 4. Regular, initiated by the chest wall, 40-60 per minute, shallow

2. Irregular, abdominal, 30-60 per minute, shallow

The nurse caring for a newborn on a ventilator for respiratory distress syndrome (RDS)informs the parents that the newborn is improving. Which of the following supports the nurse's assessment? 1.Increased PCO2 2.Increased urination 3.Decreased urine output 4.Increased pulmonary vascular resistance

2.Increased urination In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination may be an early clue that the baby's condition is improving. As fluid moves out of the lungs into the bloodstream, alveoli open, and kidney perfusion increases; this results in increased voiding.

•A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: 1. "You infant needs vitamin K to develop immunity." 2. "The vitamin K will protect your infant from being jaundiced." 3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." 4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."

•Within 3 minutes after birth the normal heart rate of the infant may range between: 1. 100 and 180 2. 130 and 170 3. 120 and 160 4. 100 and 130

3. 120 and 160

Which recommendation is the American Cancer Society guideline for early detection of BC? 1. Beginning at 18 y.o. have a biannual clinical breast exam with HCP. 2. Beginning at 30 y.o. perform monthly breast self exams. 3. Beginning at 40 y.o., receive a yearly mammogram. 4. Beginning at 50 y.o. have a breast sonogram every 5 yrs.

3. Beginning at 40 y.o., receive a yearly mammogram.

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: 1. Subcutaneous injection 2. Intravenous injection 3. Instillation of the preparation into the lungs through an endotracheal tube 4. Intramuscular injection

3. Instillation of the preparation into the lungs through an endotracheal tube In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

•A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: 1. Wrap the tape measure around the infant's head and measure just above the eyebrows. 2. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes 3. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes 4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.

3. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes

•After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? 1. Hypoglycemia 2. Jitteriness 3. Respiratory depression 4. Tachycardia

3. Respiratory depression Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. Also - ABC's.

The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow and asks if the baby should be hospitalized. What should the nurse consider as being the cause of this infant's skin color change? 1.Pathologic jaundice 2.Physiologic jaundice 3.Acute bilirubin encephalopathy 4.Hemolytic disease of the newborn

3.Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice.

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: 1. Warming the crib pad 2. Turning on the overhead radiant warmer 3. Closing the doors to the room 4. Drying the infant in a warm blanket

4. Drying the infant in a warm blanket

The nurse is teaching a class on breast health to a group of ladies at the senior center. Which is the most important risk factor to emphasize to this group? 1. Find out about family Hx of BC 2. Men at this age can get breast cancer and should also be screened. 3. Monthly self exam is the key to early detection. 4. The older a woman gets, the greater the chance of developing BC.

4. Female gender and increasing age are risk factors for developing BC

•The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? 1. Candida albicans 2. Chlamydia trachomatis 3. Escherichia coli 4. Group B beta-hemolytic streptococci

4. Group B beta-hemolytic streptococci

•A woman delivers a 3.250 g (7.5 lb) neonate at 42 weeks gestation. Which physical finding is expected during an examination if this neonate? 1. Abundant lanugo 2. Absence of sole creases 3. Breast bud of 1-2 mm in diameter 4. Leathery, cracked, and wrinkled skin

4. Leathery, cracked, and wrinkled skin

•Neonates of mothers with diabetes are at risk for which complication following birth? 1. Atelectasis 2. Microcephaly 3. Pneumothorax 4. Macrosomia

4. Macrosomia Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin. Big baby >8 lb, 13oz (>4,000g)

•When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: 1. Pulse, respirations, temperature 2. Temperature, pulse, respirations 3. Respirations, temperature, pulse 4. Respirations, pulse, temperature

4. Respirations, pulse, temperature

•Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? 1. The neonate with a temperature of 98.9°F and weight of 3,000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with respirations of 72 and heart rate of 166.

4. The neonate with respirations of 72 and heart rate of 166. These are abnormal vital signs and prompt the need for further evaluation to investigate the cause. The other answers are normal findings in a newborn. HR should be 100-160 RR should be 30-60

A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem? 1. Irritability and flushing of the skin at 8 hours of age 2. Respiratory distress syndrome developed 48 hours after birth 3. Bradycardia and tachypnea develop when the infant is 36 hours old 4.Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

4.Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

What is the priority nursing goal in helping a client during a complicated labor? A. Establish a trusting relationship. B. Ensure that the client knows what to expect. C. Prevent invasion of privacy. D. Prevent fear and anxiety.

A. Establish a trusting relationship

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? A. Notify the health care provider B. Provide health education C. Assess the client for ketonuria D. Document the client's blood pressure

A. Notify the health care provider

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously.

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication? atelectasis

Atelectasis

The client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client? A. Ask if the client is afraid of having general anesthesia. B. Determine how the client feels about radiation and chemotherapy. C. Tell the client she will need reconstruction with either procedure. D. Find out if the client has any history of breast cancer in her family.

B. Determine how the client feels about radiation and chemotherapy. If client has a lumpectomy, this will require radiation and/or chemotherapy in addition to the surgery.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature.

The client diagnosed with gestational diabetes delivered a 10-pound 5-ounce infant. Which is priority for the nursery nurse to monitor? A. Failure to latch on to the breast during feeding. B. Jaundice and clay-colored stools. C. Parchment-like skin and lack of lanugo. D. Low blood glucose readings.

D. Low blood glucose readings

Which data collected during the newborn's physical assessment support the current diagnosis of meconium aspiration syndrome?

Decreased oxygen saturation

To decrease the risk for birth asphyxia, which maternal condition should the nurse monitor for during labor and delivery?

Hypertension

Which clinical manifestations cause the nurse to report to the provider that a newborn is experiencing hypoglycemia?

Hypotonia Poor feeding Hypothermia

Common symptoms of hypoglycemia in neonate

Jitteriness poor feeding hypotonia hypothermia

Which intervention should the nurse include in the plan of care for a newborn experiencing hypoglycemia?

Making sure the baby is breastfed or bottle fed

Which newborn condition requires the nurse to closely monitor for the development of respiratory distress syndrome (RDS)?

Meconium aspiration

Risk for EOS: early onset sepsis in newborns

PROM> 18 h (rupture of membrane) Chorioamnionitis (infx placenta or amniotic fluid) GBS colonization <37 week gestation

Which intervention should the nurse include in the plan of care for a jaundiced newborn who is to receive phototherapy?

Placing eye protection on the baby during therapy

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocrit levels q12h.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

To detect rebound hypoglycemia

Which nursing action is appropriate when providing care to a newborn who is experiencing cold stress?

Warming the formula prior to feedings

Preperatively, to meet the psychological needs of a woman scheduled for a modified radical mastectomy, you would a. discuss the limitations of breast reconstruction b. include her significant other in all conversations c. promote an environment for expression of feelings d. explain the importance of regular follow-up screenings

c. promote an environment for expression of feelings

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate?

clay-colored stools tea-colored urine increased serum bilirubin levels

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply. a) loud crying b) expiratory grunting c) nasal flaring d) retractions e) tachypnea f) diaphoresis

expiratory grunting nasal flaring retractions tachypnea

Which data cause the licensed practical nurse (LPN) to notify the registered nurse (RN) when providing care for a newborn patient?

grunting with expirations

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being

large-for-gestational-age.

Common symptoms of neonatal sepsis

lethargy poor feeding poor perfusion increased RR temperature instability

Risk factors for hypoglycemia in neonate

maternal diabetes prematurity (riskiest before 27 weeks) low birth weight low APGAR, asphyxia

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

Which intervention should be included in the nursing plan of care for a newborn diagnosed with sepsis?

promoting thermoregulation

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome