CH. 24

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate?

"Forget about what's happened in the past, and focus on the now."

Assessment of a 26-week-old premature newborn reveals that the newborn is having problems with thermoregulation. The nurse would be alert for the development of which of the following?

Apnea

A nurse assesses a premature newborn and suspects hypothermia based on which of the following?

Nasal flaring

A nurse is implementing measures to prevent hypothermia in a premature newborn. The nurse determines that the newborn is experiencing an effect of hypothermia based on which assessment finding?

No breathing for 15 seconds

How can the nurse promote adequate ventilation and respiratory support in a preterm newborn? Select all that apply.

Reposition the newborn every 2 hours Suction the airway Elevate the head of the bed Observe for changes in respiratory effort Encourage organized rest times

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

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hematocrit

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? I overhead the doctor says he was LGA. What does that mean?" Which response by the nurse would be most appropriate?

"That means your baby is over the 90th percentile for weight."

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

A nurse is providing care to a large-for-gestational-age newborn. The newborn's blood glucose level was 32 mg/dl one hour ago. Breastfeeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dl. Which action would the nurse do next?

Administer intravenous glucose.

A newborn is diagnosed with hemolytic disease of the newborn. When developing the plan of care for this child, the nurse would expect which of the following to be included as part of the treatment plan?

Exchange transfusion

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping.

An 18-year-old client has given birth at 28 weeks' 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.

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?

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

A nurse is caring for a couple during a prenatal clinic visit. Which assessment finding would lead the nurse to suggest genetic counseling for the couple?

The mother suggests the prior two miscarriages were an emotional struggle for her.

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition?

diabetes

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant?

hypoglycemia

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

lethargy and hypotonia

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

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

polycythemia

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.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1,200 g, interpreting this to indicate that the newborn is of:

very low birth weight.

The nurse determines a newborn is small-for-gestational-age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

A nurse is assessing a newborn who has been classified as small for gestational age. Which characteristics would the nurse expect to find? Select all that apply.

wasted extremity appearance sunken abdomen narrow skull sutures