Chapter 32:Birth-Related Stressors

The special care nursery nurse is working with parents of a​ 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is​ unexpected?

"I've been sleeping very well since I had the​ baby."

Which nursing intervention is appropriate in the management of the preterm infant with​ hypothermia?

*Initiate efforts to maintain the newborn in a neutral thermal environment. *Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

When planning care for the premature newborn diagnosed with respiratory distress​ syndrome, which potential complications would the nurse​ anticipate?

1)Hypoxia 2)Metabolic acidosis 3)Massive atelectasis 4)Pulmonary edema

Which​ fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a​ newborn?

1)Nonreassuring fetal heart rate​ pattern/sustained bradycardia 2)History of meconium in amniotic fluid 3)Prematurity 4)Significant intrapartum bleeding

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to​ implement?

1)Obtain skin cultures. 2)Evaluate bilirubin levels. 3)Administer oxygen as ordered. 4)Observe for signs of hypoglycemia.

Which of the following are considered risk factors for development of severe​ hyperbilirubinemia?

1)Previous sibling received phototherapy 2)Exclusive breastfeeding 3)Infection

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse​ expect?

Appearance of jaundice symptoms after 24 hours of life Yellowish coloration of the sclera of the eyes

A newborn is receiving phototherapy. Which intervention by the nurse would be most​ important?

Assessment of hydration status

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate​ intervention?

Axillary temperature 99.7degreesF

The nurse notes that a​ 36-hour-old newborn's serum bilirubin level has increased from 14​ mg/dL to 16.6​ mg/dL in an​ 8-hour period. What nursing intervention would be included in the plan of care for this​ newborn?

Begin phototherapy

A laboring mother has recurrent late decelerations. At​ birth, the infant has a heart rate of​ 100, is not​ breathing, and is limp and bluish in color. What nursing action is​ best?

Begin​ bag-and-mask ventilation.

The nurse is assessing the newborn for symptoms of anemia. If the blood loss is​ acute, the baby may exhibit which of the following signs of​ shock?

Capillary filling time greater than 3 seconds Tachycardia

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the​ following?

Chlamydia

Which nursing interventions are appropriate when caring for the newborn undergoing​ phototherapy?

Close the​ newborn's eyelids before applying eye patches. Inspect the eyes each shift for conjunctivitis. Reposition the baby every 2 hours.

A client in labor is found to have​ meconium-stained amniotic fluid upon rupture of membranes. At​ delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse​ anticipate?

Direct tracheal suctioning by specially trained personnel.

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial​ assessment?

Hemoglobin Hematocrit Reticulocyte count Direct​ Coombs' test

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome​ (RDS). The nurse informs the parents that the newborn is improving. Which data support the​ nurse's assessment?

Increased urination

The nurse prepares to admit to the nursery a newborn whose mother had​ meconium-stained amniotic fluid. The nurse knows this newborn might require which of the​ following?

Initial resuscitation

One day after giving birth​ vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her​ neonate?

Intravenous acyclovir​ (Zovirax) and contact precautions.

Mild or chronic anemia in an infant may be treated adequately which of the​ following?

Iron supplements or​ iron-fortified formulas

Which assessment findings by the nurse would require obtaining a blood glucose level on the​ newborn?

Jitteriness

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the​ fiber-optic blanket is beneficial because of which of the​ following?

Newborns do not get overheated. Weight loss is not a complication of this system. Lights can stay on all the time. The eyes do not need to be covered.

The nurse is preparing an educational​ in-service presentation about jaundice in the newborn. What content should the nurse include in this​ presentation?

Physiologic jaundice occurs after 24 hours of age. Kernicterus causes irreversible neurological damage.

A nurse explains to new parents that their newborn has developed respiratory distress syndrome​ (RDS). Which of the following signs and symptoms would not be characteristic of​ RDS?

Respiratory rate of 40 during sleep

Which findings would the nurse expect when assessing a newborn infected with​ syphilis?

Rhinitis Fissures on mouth corners Red rash around anus

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate​ intervention?

Room-temperature IV running

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit​ reading, what does the nursing instructor tell the student​ do?

Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.

What indications would lead the nurse to suspect sepsis in a​ newborn?

Temperature of 97.0degreesF 2 hours after warming the infant from 97.4degreesF

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to​ phototherapy?

The newborn maintains a normal temperature

During newborn​ resuscitation, how does the nurse evaluate the effectiveness of​ bag-and-mask ventilations?

The rise and fall of the chest

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

Transient tachypnea of the newborn

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this​ care?

Urine specific gravity is assessed each voiding.

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the​ following?

​"Visits must be scheduled between​ feedings."

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is​ best?

​"Your baby is working hard to breathe and lying quite​ still, and has an​ IV."

The client with blood type O​ Rh-negative has given birth to an infant with blood type O​ Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the​ nurse?

​"Your body has made antibodies against the​ baby's blood that are destroying her red blood​ cells."