Maternal-Newborn Ch 24 Care Related to Gestational Age, Size, Injury, and Pain in the Newborn

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has occurred when a participant makes which statement? "Appropriate for gestational age means a newborn is born with a weight that falls in the 10th percentile." "Newborns who are appropriate for gestational age at birth have lower chance of complications than others." "Appropriate for gestational age describes a newborn with a weight over the 90th percentile at birth." "Infants who are larger for gestational age at birth have fewer complications than the other groups."

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement? "The ability of my amniotic fluid to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my umbilical cord to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my body to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be increased." "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

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

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion? 40 mg/dL 50 mg/dL 30 mg/dL 60 mg/dL

30 mg/dL

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: 4,000 g or more. 3,500 g or more. 4,500 g or more. 3,000 g or more.

4,000 g or more.

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

40 mg/100 mL whole blood

A nurse is documenting the weights of several newborns and determines them to be appropriate for gestational age (AGA). Which percentile would the nurse identify for this classification? Select all that apply. 35 50 80 5 95

50 80 35

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply. Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Bathe the neonate with warmer water. Minimize kangaroo care. Encourage skin-to-skin contact.

Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Encourage skin-to-skin contact.

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.

Closely monitor temperature.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care? Clustering care and activities Giving a bath Administering medications Holding the infant

Clustering care and activities

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? Suggest that the parents stay for just a few minutes to reduce their anxiety. Reassure them that their newborn is progressing well. Encourage the parents to touch their preterm newborn. Discuss the care they will be giving the newborn upon discharge.

Encourage the parents to touch their preterm newborn.

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 Surfactant administration Radiant warming Mechanical ventilation

Exchange transfusion

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.

Focus on decreasing blood viscosity by increasing fluid volume

The nurse is teaching gavage feedings to the mother of a preterm infant. Which instruction is most important? Amount of feeding Expelling of gas Gastric residual present Quantity of bowel movement

Gastric residual present

The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication? Affinity of the preterm fetus to fat-soluble drugs Inability of the immature liver to metabolize or inactivate drugs Affinity of the preterm fetus to drugs that are strongly bound to protein Inability of the preterm fetus to use drugs with a molecular weight over 1,000

Inability of the immature liver to metabolize or inactivate drugs

A newborn is diagnosed with a patent ductus arteriosus and despite supportive treatment, the newborn continues to exhibit symptoms. Which of the following would the nurse anticipate as being prescribed? Indomethacin Aspirin Surfactant Penicillin

Indomethacin

Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing? Ineffective thermoregulation related to immaturity Risk for imbalanced nutrition, less than body requirements Risk for deficient fluid volume related to insensible water loss Impaired gas exchange related to immature pulmonary functioning

Ineffective thermoregulation related to immaturity

The nurse is weighing and measuring a term newborn. The nurse should question this baby is suffering from asymmetrical intrauterine growth restriction based on which assessment findings? Looks wasted and has poor skin turgor Is pale with loose, dry skin Has cracked and leathery skin Has very thin skin and has multiple visible veins

Is pale with loose, dry skin

Why does breathing require greater effort for the preterm newborn? Lack of surfactant Lack of a hyaline membrane Lack of alveoli Lack of a fibrous membrane

Lack of surfactant

The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent further complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn? Decreased muscle tone Loss of body heat Excess antibodies acquired from the mother Increased caloric intake

Loss of body heat

A nurse assesses a premature newborn and suspects hypothermia based on which of the following? Regular respirations Oxygen saturation of 95% Pink skin Nasal flaring

Nasal flaring

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy? Glucose is 60 mg/dl (3.3 mmol/L). Heart rate is 60 bpm. Oxygen saturation levels are at 98%. PaCO2 is 35 to 45 mm Hg.

Oxygen saturation levels are at 98%

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? The infant may sleep through the night around 2 months of age. Caregivers need to sleep while the baby is sleeping. Newborns usually sleep for 16 or more hours each day. Place the infant on the back when sleeping.

Place the infant on the back when sleeping.

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 hematocit levels q12h. Continue to monitor blood glucose levels q6h. Review maternal history for bleeding disorders. Prepare for continued positive airway pressure.

Prepare for repeat hematocit levels q12h.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? Deep inspiration Expiratory lag Sternal retraction Inspiratory grunt

Sternal retraction

Which sign appears early in a neonate with respiratory distress syndrome? Bilateral crackles Pale gray skin color Tachypnea more than 60 breaths/minute Poor capillary filling time (3 to 4 seconds)

Tachypnea more than 60 breaths/minute

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? "Yes, as they lack the antibody called IdD that acts as protection from infections." "Not really, as premature infants are cared for in an isolate, protecting them from infection." "Feeding premature infants breast milk establishes the best protective mechanisms." "That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

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

At birth, the newborn was at the 8th percentile with a weight of 2350g 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 a very low birth weight and small for gestational age The infant was a preterm, very low birthweight and small for gestational age

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

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? Conduction heat loss is a problem in the baby. The supply of brown adipose tissue is not developed. Axillary temperatures are not accurate. This is a normal temperature.

The supply of brown adipose tissue is not developed

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? shivering hyperglycemia apnea metabolic alkalosis

apnea

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? apnea tachycardia sleepiness crying

apnea

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 temperature instability seizures feeble sucking

asymmetrical movement

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. clustering care to promote rest positioning newborn in extension using kangaroo care loosely covering the newborn with blankets providing non nutritive sucking

clustering care to promote rest using kangaroo care providing non nutritive sucking

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. clustering care to promote rest positioning newborn in extension using kangaroo care loosely covering the newborn with blankets providing nonnutritive sucking

clustering care to promote rest using kangaroo care providing nonnutritive sucking

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. diabetes mellitus postdates gestation alcohol use prepregnancy obesity renal infection

diabetes mellitus postdates gestation prepregnancy obesity

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. foramen ovale closes prematurely. aorta or aortic valve strictures. pulmonary artery closes.

ductus arteriosus remains open.

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? fewer visible blood vessels through the skin more subcutaneous fat in the neck and abdomen well-developed flexor muscles in the extremities greater surface area in proportion to weight

greater surface area in proportion to weight

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 hyperglycemia hypotension hypertension

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 sudden high-pitched cry increased muscle tone fussiness

lack of body posturing

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. small-for-gestational-age. appropriate-for-gestational-age. very-large-for-gestational-age.

large-for-gestational-age.

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? increased appetite increase in the body temperature lethargy and hypotonia hyperglycemia

lethargy and hypotonia

A nurse is conducting a class for expectant parents about newborns. As part of the class, the nurse describes newborns with birth weight variations. The nurse identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? small for gestational age low birth weight very low birth weight extremely low birth weight

low birth weight

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

meconium aspiration in utero or at birth

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? fracture of the tibia fracture of the femur fracture of a rib midclavicular fracture

midclavicular fracture

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 increased amount of breast tissue sunken abdomen adequate muscle tone over buttocks narrow skull sutures

narrow skull sutures wasted extremity appearance sunken abdomen

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in maternal history would the nurse correlate as a risk factor for an SGA infant? placental factors blood group incompatibility grand multiparity age of 30 years

placental factors

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment? stabilized respiratory effort absence of apnea stabilized cardiac function presence of bowel sounds

stabilized respiratory effort

A newborn girl who was born at 38 weeks of 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

term, small for gestational age, and low-birth-weight infant

A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation? moist, supple, plum skin appearance abundant lanugo and vernix thin umbilical cord absence of sole creases

thin umbilical cord

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

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