Chapter 35: Acquired Problems of the Newborn

During a prenatal examination, a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. The client questions the nurse as to why. What is the nurse's most appropriate response? a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the HIV in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby."

A. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. Approximately 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although cleaning the litter boxes is "just gross," this statement is not appropriate, fails to answer the client's question, and is not the nurse's best response

Which substance, when abused during pregnancy, is the most significant cause of cognitive impairment and dysfunction in the infant? a. Alcohol b. Tobacco c. Marijuana d. Heroin

A. Alcohol Alcohol abuse during pregnancy is recognized as one of the leading causes of neurodevelopmental disorders in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes; the risk for placenta previa, placenta abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of IUGR.

A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

A. Alcohol The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy

A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the face and upper back. Which information regarding petechiae is most accurate and should be provided to the parents? a. Are benign if they disappear within 48 hours of birth b. Result from increased blood volume c. Should always be further investigated d. Usually occur with a forceps-assisted delivery

A. Are benign if they disappear within 48 hours of birth. Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of childbirth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, alarming the family is not necessary. Petechiae usually occur with a breech presentation vaginal birth.

A number of common drugs of abuse may cross into the breast milk of a mother who is currently using these substances, which may result in behavioral effects in the newborn. Which substances are contraindicated if the mother elects to breastfeed her infant? (Select all that apply.) a. Cocaine b. Marijuana c. Nicotine d. Methadone e. Morphine

A. Cocaine B. Marijuana C. Nicotine The use of cocaine, marijuana, and nicotine are contraindicated during breastfeeding because of their reported effects on the infant. Morphine is a medication often used to treat neonatal abstinence syndrome. Maternal methadone maintenance is not a contraindication to breastfeeding

What is the most important nursing action in preventing neonatal infection? a. Good handwashing b. Isolation of infected infants c. Separate gown technique d. Standard Precautions

A. Good handwashing Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of health care-associated infection in nursery units. Overcrowding must be avoided in nurseries, and infants with infectious processes should be isolated. Separate gowns should be worn in caring for each infant in the special care nursery. Soiled linens should be disposed of in an appropriate manner. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Ideally infants should remain with their mothers

Which information regarding to injuries to the infant's plexus during labor and birth is most accurate? a. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. Parents of children with brachial palsy are taught to pick up the child from under the axillae. d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months. If the nerves are stretched with no avulsion, then they should recover completely in 3 to 6 months. However, if the ganglia are completely disconnected from the spinal cord, then the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and the infant will need help from the nurse at the start.

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant's care? a. Prone positioning facilitates bone alignment. b. No special treatment is necessary. c. Parents should be taught range-of-motion exercises. d. The shoulder should be immobilized with a splint.

B. No special treatment is necessary. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. Performing range-of-motion exercises on the infant is not necessary. A fractured clavicle does not require immobilization with a splint

The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth? a. Newborn's skull is still forming and fractures fairly easily. b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. c. Clavicle fractures often need to be set with an inserted pin for stability. d. Other than the skull, the most common skeletal injuries are to leg bones.

B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" How should the nurse respond? a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is prophylactically given to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

C. "Erythromycin is prophylactically given to prevent a gonorrheal infection." With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is given to prevent infection, not for lubrication.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition? a. Gonorrhea b. Herpes simplex virus (HSV) infection c. Congenital syphilis d. HIV

C. Congenital syphilis A copper-colored maculopapular rash is indicative of congenital syphilis with lesions that may extend over the trunk and extremities. This rash is not an indication that the neonate has contracted gonorrhea. Rather, the neonate with gonorrheal infection might have septicemia, meningitis, conjunctivitis, and scalp abscesses. Infants affected with the HSV display growth restriction, skin lesions, microcephaly, hypertonicity, and seizures. Typically, the HIV-infected neonate is asymptomatic at birth. Most often the infant develops an opportunistic infection and rapid progression of immunodeficiency

An infant was born 2 hours ago at 37 weeks of gestation and weighs 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of what condition? a. Birth injury b. Hypocalcemia c. Hypoglycemia d. Seizures

C. Hypoglycemia Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate? a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from vacuum-assisted deliveries.

C. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomographic (CT) scans might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. Spinal cord injuries are almost always from breech births; however, spinal cord injuries are rare today because cesarean birth is used for breech presentation

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. What is the first step in the provision of care for the infant? a. Pharmacologic treatment b. Reduction of environmental stimuli c. Neonatal abstinence syndrome (NAS) scoring d. Adequate nutrition and maintenance of fluid and electrolyte balance

C. Neonatal abstinence Syndrome (NAS) Scoring NAS describes the cohort of symptoms associated with drug withdrawal in the neonate. The NAS system evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal (GI) disturbances. This evaluation tool enables the health care team to develop an appropriate plan of care. The infant is scored throughout his or her length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of the withdrawal symptoms, which are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage

Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing? a. Iron deficiency anemia b. Hyponatremia c. Respiratory distress syndrome d. Sepsis

C. Respiratory Distress Syndrome IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or sepsis.

For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care? a. Administering chloral hydrate for sedation b. Feeding every 4 to 6 hours to allow extra rest between feedings c. Snugly swaddling the infant and tightly holding the baby d. Playing soft music during feeding

C. Snugly swaddling the infant and tightly holding the baby. The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because stimulation will increase activity and potentially increase CNS irritability.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse's first priority? a. Leave the infant in the room with the mother. b. Immediately take the infant to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia

D. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than 4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants. Blood glucose levels should be frequently monitored, and the infant should be closely observed for signs of hypoglycemia. Close observation can be achieved in the mother's room with nursing interventions. However, depending on the condition of the infant, observation may be more appropriate in the nursery

What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococci (GBS) infection

D. Group B Stretococci (GBS) infection Penicillin has significantly decreased the incidence of GBS infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and in Canada. Candidiasis is a fairly benign fungal infection

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress? a. Hypoglycemia b. Phrenic nerve injury c. Respiratory distress syndrome d. Sepsis

D. Sepsis The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually the result of traction on the neck and arm during childbirth and is not applicable to this situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy, poor feeding, irritability), not respiratory distress syndrome.

Human immunodeficiency virus (HIV) may be transmitted perinatally or during the postpartum period. Which statement regarding the method of transmission is most accurate? a. Only in the third trimester from the maternal circulation b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

D. Through the ingestion of breast milk from an infected mother. Postnatal transmission of the HIV through breastfeeding and breast milk may occur. Transmission of the HIV from the mother to the fetus may occur through the placenta at various gestational ages. Transmission of the HIV from the use of unsterile instruments is highly unlikely; most health care facilities must meet sterility standards for all instrumentation.