Chapter 23 prepU
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? The skin is pale, and no vessels show through it. Creases appear on the interior two-thirds of the sole. The pinna of the ear is soft and flat and stays folded. The neonate has 7 to 10 mm of breast tissue.
Correct response: The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.
Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? total bilirubin level of 15 respiratory rate of 60 to 70 bpm heart rate of 162 bpm hematocrit of 44%
Correct response: respiratory rate of 60 to 70 bpm Explanation: The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid.
A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? term, small-for-gestational-age, and low-birth-weight infant term, small-for-gestational-age, and very-low-birth-weight infant late preterm and appropriate for gestational age late preterm, large-for-gestational-age, and low-birth-weight infant
Correct response: term, small-for-gestational-age, and low-birth-weight infant Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response? "Your infant's cardiovascular system is not developed yet in order to sustain respiration." "Most preterm infants require additional oxygen through ventilation to sustain respiration." "Premature infants have a respiratory system that takes time to adjust to extrauterine life." "Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."
Correct response: "Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Explanation: Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.
A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl (1.28 mmol/L). The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? Administer dextrose intravenously. Monitor the infant's hematocrit levels closely. Administer PO glucose water immediately. Place the infant on a radiant warmer.
Correct response: Administer dextrose intravenously. Explanation: The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg/dL (2.22 mmol/L), and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand.
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. Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance.
Correct response: Closely monitor temperature. Explanation: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.
A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of: aging placenta. hypoxia from cord compression. loss of subcutaneous fat. increased production of red blood cells.
Correct response: aging placenta. Explanation: Complications associated with a postterm newborn include perinatal asphyxia (caused by placental aging or oligohydramnios [decreased amniotic fluid]), hypoglycemia (caused by acute episodes of hypoxia related to cord compression, which exhausts carbohydrate reserves), hypothermia (caused by loss of subcutaneous fat), and polycythemia (caused by an increased production of red blood cells to compensate for a reduced oxygen environment).
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 100 mg/100 ml whole blood 80 mg/100 ml whole blood 40 mg/100 ml whole blood 30 mg/100 ml whole blood
Correct response: 40 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 ml whole blood is considered hypoglycemia.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? Begin early feedings either by the breast or bottle. Give dextrose intravenously before oral feedings. Place infant on radiant warmer immediately. Focus on decreasing blood viscosity by introducing feedings.
Correct response: Begin early feedings either by the breast or bottle. Explanation: The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.
The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action? Begin supervised feedings for the newborn. Return the newborn to its parents for bonding. Transfer the newborn to the neonatal intensive care unit. Recheck the newborn's blood glucose in 4 hours.
Correct response: Begin supervised feedings for the newborn. Explanation: Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. Supervised breastfeeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.
A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? Focus on decreasing blood viscosity by increasing fluid volume. Check blood glucose within 2 hours of birth by reagent test strip. Repeat screening every 2 to 3 hours or before feeds. Focus on monitoring and maintaining blood glucose levels.
Correct response: Focus on decreasing blood viscosity by increasing fluid volume. Explanation: The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.
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 The infant was born at term but at a low birth weight and small-for-gestational age The infant was born at term but at a very low birth weight and small-for-gestational-age The infant was a preterm, very-low-birthweight and small-for-gestational-age
Correct response: The infant was a preterm, low-birth-weight and small-for-gestational-age Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.
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. The infant may have excess of lanugo and vernix caseosa. The testes in the child may be undescended. The newborn may have short nails and hair.
Correct response: The newborn may look wrinkled and old at birth. Explanation: Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: inspiratory stridor. expiratory grunting. expiratory wheezing. inspiratory "crowing."
Correct response: expiratory grunting. Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).
What is a consequence of hypothermia in a newborn? respirations of 46 heart rate of 126 holds breath 25 seconds skin pink and warm
Correct response: holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.
An infant who is diagnosed with meconium aspiration displays which symptom? intercostal and substernal retractions pink skin respirations of 45 no heart murmur
Correct response: intercostal and substernal retractions Explanation: Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.
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 seizures, respiratory distress, cyanosis, and shrill cry yellow appearance of the newborn's skin tremors, irritability, and high-pitched cry
Correct response: meconium aspiration in utero or at birth Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.
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 wasted appearance of extremities, gelatinous umbilical cord, and abundant subcutaneous fat stores reduced subcutaneous fat stores to buttocks, thicker umbilical cord, and smaller head compared to body normal subcutaneous fat stores, cord-like umbilical cord, and increased development to extremities
Correct response: wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores Explanation: The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.