NURS 3 - Mod 8 Monitoring the newborn (Maternity) EAQ's

The parent of a newborn reports to the nurse, "My baby has small, red papules on the face and hands." What response should the nurse give to the parent? 1 "The skin reaction is normal." 2 "The spots are due to cyanosis." 3 "The baby has adequate oxygen supply." 4 "The skin rash is due to direct sunlight exposure."

1 - "The skin reaction is normal." The newborn has small, red papules on her face and hands that indicate transient rashes due to erythema toxicum. This condition is not clinically significant and does not require any treatment. Cyanosis is the appearance of a bluish tint on the skin, but it is not accompanied by small, red papules on the body. Adequate oxygen supply does not lead to small, red-colored papules on the skin. Exposure to direct sunlight does not lead to the formation of papule-like lesions on the skin.

The nurse is providing neonatal care to a newborn who is in the period of decreased responsiveness. Which physiologic and behavioral findings does the nurse expect in the newborn? Select all that apply. 1 The newborn is pink. 2 The newborn will be asleep. 3 The newborn has mucus production. 4 The newborn has slow, labored respirations. 5 The newborn's heart rate increases to 160 bpm.

1 - The newborn is pink. 2 - The newborn will be asleep. During the period of decreased responsiveness, the newborn sleeps or has a marked decrease in motor activity, and is pink. During the first period of reactivity, the newborn's heart rate increases rapidly to 160-180 bpm, but gradually falls after 30 minutes or so. Mucus production occurs in the second period of reactivity, which occurs approximately two to eight hours after birth. During the period of decreased responsiveness, respirations are rapid, shallow, and unlabored, not slow and labored.

Which conditions is the nurse alert for in a preterm infant with respiratory distress syndrome? Select all that apply. 1 Jaundice 2 Hypoxemia 3 Mucus plugging 4 Metabolic acidosis 5 Pulmonary hemorrhage

2 - Hypoxemia 4 - Metabolic acidosis Inadequate pulmonary perfusion and ventilation produce hypoxemia and hypercapnia in the preterm infant. Prolonged hypoxemia increases the amounts of lactic acid and results in metabolic acidosis. Pulmonary hemorrhage and mucus plugging are side effects of surfactant therapy used in an infant with respiratory distress syndrome. Jaundice is not caused by respiratory distress syndrome. It occurs because of an increase in bilirubin levels in the blood.

The nurse advises the postpartum patient to breastfeed regularly to lower her risk for postpartum hemorrhage. The reason behind this suggestion is that this method of feeding increases what? 1 Lactose production 2 Oxytocin production 3 Estrogen production 4 Progesterone production

2 - Oxytocin production Breast milk production follows the supply-meets-demand system. The more the patient breastfeeds the infant, the greater the demand for production. This, in turn, increases the production of oxytocin. Oxytocin is the hormone that helps in uterine contraction and involution and decreases the risk of postpartum hemorrhage. Other hormones are present at the appropriate levels but are not related to postpartum hemorrhage.

The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, what should the nurse do? 1 Notify the physician because the newborn is being poorly nourished 2 Refer the mother to a lactation consultant to improve her breastfeeding technique 3 Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs 4 Suggest that the mother switch to bottle-feeding because the breastfeeding is ineffective in meeting newborn needs for fluid and nutrients

3 - Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs Weight loss of 8 ounces falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. Breastfeeding is effective at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this time. The infant is not undernourished, and the physician does not need to be notified. The weight loss is within normal limits; breastfeeding is effective.

Which condition may be seen in an infant born to a patient who consumed excessive alcohol during pregnancy? 1 Skull fractures 2 Hypothyroidism 3 Respiratory distress 4 Congenital abnormalities

4 - Congenital abnormalities Infants born to mothers who are heavy alcohol drinkers are at risk for congenital abnormalities. Respiratory distress is not usually seen in an infant exposed to alcohol. Hypothyroidism is a genetic disorder not related to alcohol consumption. Skull fractures are sometimes caused during a difficult birth as a result of the pressure of the fetal skull against the maternal pelvis.

What is a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? 1 Apical heart rate of 90 beats/min, slightly irregular, when awake and active 2 Acrocyanosis 3 Harlequin color sign 4 Weight loss representing 5% of the newborn's birth weight

1 - Apical heart rate of 90 beats/min, slightly irregular, when awake and active The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

While the infant is sleeping, the nurse finds that the infant's heart rate is 60 beats/minute. What should the nurse do in this situation? 1 Immediately wake the infant. 2 Reassess the heart rate after 30 minutes. 3 Advise the mother to stop breastfeeding. 4 Inform the parents that the infant has bradycardia.

2 - Reassess the heart rate after 30 minutes. The average heart rate of infants is 120 to 160 beats/minute and varies based on the infant's activity. When the infant is in a state of rest, such as sleeping, the heart rate decreases to 85 to 100 beats/minute. If the heart rate reduces to 60 beats/minute (less than 85 beats/minute), then the nurse should reassess the heart rate either 30 or 60 minutes later to check for any cardiovascular diseases. Waking the infant suddenly from sleep may irritate and make the infant fussy and distressed. Without a thorough assessment, the nurse should not conclude and inform the parents that the infant has bradycardia. The nurse should also not advise the infant's mother to stop breastfeeding, as it leads to malnutrition in the infant and it is unlikely related to the variation in the heart rate.

The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate's BP confirm a cardiac defect? 1 The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg. 2 The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. 3 The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg. 4 The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.

2 - The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. Systolic BP should be 60 to 80 mm Hg, and diastolic BP should be 40 to 50 mmHg. When the recordings are varied by 20 mm Hg in both the extremities, it implies that the neonate has a cardiac defect, such as coarctation of the aorta. If the BP of the lower extremities is 50/40 mm Hg and that of the upper extremities is 80/70 mm Hg, it indicates that the neonate has a cardiac defect, such as coarctation of the aorta. The same recordings on all the extremities signify that the neonate's heart functions properly. Variations of 10 mm Hg are still considered a normal finding in a neonate.

The nurse is assessing an infant born after 42 weeks of gestation. Which characteristics may be seen in the infant? Select all that apply. 1 Soft cranium 2 Weak gag reflex 3 Green vernix caseosa 4 Small, scrawny appearance 5 Wasted physical appearance

3 - Green vernix caseosa 5 - Wasted physical appearance An infant born after 42 weeks of gestation is a postterm infant. The infant may have a wasted physical appearance that indicates intrauterine deprivation. There is little green or deep yellow vernix caseosa in the infant's skinfolds, which indicates meconium in the amniotic fluid. Weak gag reflex, small and scrawny appearance, and a soft cranium are characteristics of a preterm infant.

The nurse tells a postpartum patient to gently massage her breasts before performing hand expression. Why the nurse did give such an instruction? 1 Massage will prevent nipple trauma. 2 Massage will reduce body temperature. 3 Massage will stimulate the let-down reflex. 4 Massage will reduce pain during expression.

3 - Massage will stimulate the let-down reflex Gentle massage before hand expression is recommended to stimulate the let-down reflex or milk ejection reflex, which increases milk production. This intervention is not useful to prevent nipple trauma, reduce body temperature, or reduce pain during expression. Nipple trauma can be prevented by placing the finger at the side of the infant's mouth to reduce the suction while separating the lips from the nipples. Body temperature and pain can be reduced by taking antipyretics or analgesics.

The nurse is assessing a postpartum Hmong patient who has come for a follow-up 15 days after childbirth. What diet would the patient follow to increase milk production and nourishment? 1 Seaweed soup and rice 2 Honey and clarified butter 3 Fresh fruits and vegetables 4 Boiled chicken and hot water

4 - Boiled chicken and hot water According to the cultural beliefs of Hmong women, boiled chicken, rice, and hot water provide good nourishment in the first postpartum month. Koreans consider seaweed soup and rice good for postpartum women. Honey and clarified butter are considered to be good for postpartum women in Southern Asia and the Pacific Islands. Lactating mothers belonging to Indian, Chinese, and Arab communities prefer fresh fruits and vegetables in their diet.

A patient who used cocaine during pregnancy asks the nurse about feeding the infant. The infant is being treated for cocaine withdrawal symptoms. After further discussion, the nurse finds that the patient is not willing to participate in the drug rehabilitation program and still uses cocaine frequently. What does the nurse instruct the patient related to infant nutrition? 1 "Avoid breastfeeding the child." 2 "The child needs parenteral nutrition." 3 "Avoid using infant formulas for the child." 4 "Breastfeeding may be good for the child."

1 - "Avoid breastfeeding the child." The nurse instructs the parent to avoid breastfeeding the infant because significant amounts of cocaine are found in breast milk. Breastfeeding may expose the child to further complications. The nurse encourages the parent to use infant formulas because they are safe for the infant. Parenteral nutrition is not needed unless the infant is unable to feed orally.

Which infant is a likely candidate for receiving exogenous surfactant? 1 An infant with hypoglycemia born to a diabetic mother 2 A preterm infant with respiratory distress syndrome at birth 3 A preterm infant with a soft cranium who is at risk for cranial molding 4 An infant at risk for inborn errors of metabolism, such as galactosemia

2 - A preterm infant with respiratory distress syndrome at birth Exogenous surfactant helps maintain lung expansion in infants with respiratory distress syndrome. Oral glucose is used for an infant with hypoglycemia at birth. A preterm infant is placed on a waterbed or a gel mattress to minimize the risk of cranial molding. Galactosemia is managed by eliminating lactose-containing food and milk from the infant's diet.

The nurse is caring for a new mother who reports that her 6-month-old infant has started to wean. Which statement made by the new mother indicates to the nurse that the mother needs additional teaching on the weaning process? 1 "My baby initiated the weaning on his own." 2 "My spouse says that I've been more emotional lately." 3 "I've been giving my baby small amounts of cow's milk." 4 "I am weaning my baby directly from my breast to a cup."

3 - "I've been giving my baby small amounts of cow's milk." When an infant is weaned before one year of age, the infant should be given iron-fortified formula instead of cow's milk. Weaning can be initiated by either the infant or the mother. It is common for mothers to feel emotional and even grieve during weaning, as it signifies the end of an important stage between the mother and the child. Infants can be weaned directly from the breast to the cup.

The nurse is assessing an infant after a difficult birth. Which signs in the infant indicate Erb's palsy? Select all that apply. 1 A grasp reflex may be present in the infant. 2 The infant's arm hangs limp alongside the body. 3 The elbow is extended, and the forearm is pronated. 4 The hand muscles are paralyzed, and there is a wrist drop. 5 The shoulder and the arm are adducted and rotated internally.

1 - A grasp reflex may be present in the infant. 2 - The infant's arm hangs limp alongside the body. 3 - The elbow is extended, and the forearm is pronated. 5 - The shoulder and the arm are adducted and rotated internally. Erb's palsy is caused when the upper plexus is damaged. It results from stretching or pulling away of the shoulder from the head during a difficult birth. As a result the infant's arm hangs limp alongside the body. The shoulder and the arm are adducted and rotated internally because of the paralysis of the affected extremity. The elbow is extended, and the forearm is pronated with the wrist and fingers flexed. A grasp reflex may be present because the finger and wrist movement remain normal. The infant's hand muscles are paralyzed, and there is a wrist drop in lower-plexus palsy. This results from the stretching of the upper extremity while the trunk is less mobile.

Which statement indicates the effect of breastfeeding on the family or society at large? Select all that apply. 1 Breastfeeding saves families money. 2 Breastfeeding benefits the environment. 3 Breastfeeding results in reduced annual health care costs. 4 Breastfeeding costs employers in terms of time lost from work. 5 Breastfeeding requires fewer supplies and less cumbersome equipment.

1 - Breastfeeding saves families money. 2 - Breastfeeding benefits the environment. 3 - Breastfeeding results in reduced annual health care costs. 5 - Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. Breastfeeding saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Less time is lost from work by breastfeeding mothers, in part because infants are healthier. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal. Breastfeeding results in reduced annual health care costs.

Which nursing interventions are included in the plan of care of an infant with septicemia? Select all that apply. 1 Encouraging the parent to breastfeed the infant 2 Implementing isolation procedures as instructed 3 Administering fluids and antibiotics simultaneously 4 Performing routine suctioning to prevent complications 5 Administering antibiotics within 1 hour after they are prepared

1 - Encouraging the parent to breastfeed the infant 2 - Implementing isolation procedures as instructed 5 - Administering antibiotics within 1 hour after they are prepared The nurse administers antibiotics to the infant within 1 hour after they are prepared to avoid the loss of drug stability. The nurse implements isolation procedures as instructed to prevent the risk of infection in the infant. The nurse encourages the parent to breastfeed the infant because breast milk contains protective mechanisms that provide a barrier to infection. Fluids and antibiotics are not administered simultaneously because they may interact and deactivate the drug. Suctioning is performed only when it is needed because routine suctioning may cause hypoxia and thus increase intracranial pressure.

What is the priority teaching tip the nurse should provide about bottle-feeding? 1 Hold infant semi-upright while feeding 2 Feed newborn at least every 3 to 4 hours 3 Some infants take longer to feed than others 4 Infants may stool with each feeding in the first weeks

1 - Hold infant semi-upright while feeding Infants should be held and never left alone while feeding. Never prop the bottle. The infant might inhale formula or choke on any that was spit up. Airway is priority. Taking a few sucks and then pausing briefly before continuing to suck again is normal for infants. The infant may have a stool with each feeding in the first 2 weeks, although this amount may decrease to one or two stools each day. Newborns should be fed at least every 3 to 4 hours and should never go longer than 4 hours without feeding until a satisfactory pattern of weight gain is established. Some infants take longer to feed than others. Be patient. Keep the baby awake; encouraging sucking may be necessary. Moving the nipple gently in the infant's mouth may stimulate sucking.

Which actions does the nurse take while counseling anxious parents who visit their preterm infant in an neonatal intensive care unit? Select all that apply. 1 Informs the parents of visiting hours. 2 Avoids telling the parents any unpleasant facts. 3 Encourages the parents to express their sadness. 4 Persuades the parents to touch and hold the infant. 5 Explains the function of each piece of equipment used.

1 - Informs the parents of visiting hours. 3 - Encourages the parents to express their sadness. 5 - Explains the function of each piece of equipment used. The nurse explains the function of each piece of equipment that is attached to the infant because this helps lessen fears and anxiety in the parents. The nurse may further alleviate their anxiety by informing them that they can visit the infant anytime. The nurse encourages the parents to express feelings of sadness so that they are better able to focus on their infant. The nurse needs to inform the parents honestly about all of the infant's conditions. The parents may not be ready to touch or hold the infant because of fear. Therefore the nurse should not persuade the parents to do so and should let the parents adjust to the infant's condition.

Which infants are classified as being high risk? Select all that apply. 1 Postterm (postmature) infants 2 Small-for-gestational-age (SGA) infants 3 Extremely low-birth-weight (ELBW) infants 4 Intrauterine growth restriction (IUGR) infants 5 Appropriate-for-gestational-age (AGA) infants

1 - Postterm (postmature) infants 2 - Small-for-gestational-age (SGA) infants 3 - Extremely low-birth-weight (ELBW) infants 4 - Intrauterine growth restriction (IUGR) infants ELBW infants have a birth weight less than 1000 g. They are susceptible to infections, environmental stress, and respiratory diseases. IUGR is a term for infants who have restricted intrauterine growth. The lack of maturity seen in these infants compromises their immune system. The birth weight of SGA infants falls below the 10th percentile on intrauterine growth curves. It makes these infants susceptible to respiratory disorders and other diseases. A postterm infant is born at 42 weeks' gestation, which extends beyond the full-term pregnancy. The infant may sometimes have progressive placental dysfunction. AGA infants are not high risk infants because their weights fall between the 10th and 90th percentiles on intrauterine growth curves.

Which interventions does the nurse implement while providing care for an infant with neonatal abstinence syndrome (NAS)? Select all that apply. 1 Provides dim lights in the room 2 Avoids wrapping the infant tightly 3 Reduces noise levels in the room 4 Assesses the infant's skin regularly 5 Encourages the mother to breastfeed

1 - Provides dim lights in the room 3 - Reduces noise levels in the room 4 - Assesses the infant's skin regularly 5 - Encourages the mother to breastfeed NAS refers to certain behaviors exhibited by infants who were exposed to drugs in the uterus. The nurse provides dim lights and reduces the noise levels in the infant's room to decrease hyperactivity and irritability in the infant. The nurse encourages breastfeeding to promote mother-infant bonding. The nurse assesses the infant's skin regularly because rubbing on bed linens may cause skin breakdown in the infant. Wrapping tightly is beneficial because it limits the infant's ability to self-stimulate and decreases hyperactivity.

A preterm infant is receiving oxygen therapy for respiratory distress syndrome. Which are the important nursing interventions to be included in the plan of care? Select all that apply. 1 Providing mouth care 2 Suctioning twice a day 3 Monitoring continuously 4 Assessing skin regularly 5 Positioning the infant on the side

1 - Providing mouth care 3 - Monitoring continuously 4 - Assessing skin regularly 5 - Positioning the infant on the side The nurse needs to monitor the oxygen therapy continuously because the infant's status can change rapidly and the oxygen concentration parameters may need to be changed. The nurse also assesses the infant's skin regularly because excessive rubbing on the bedsheet can increase the risk of skin breakdown. The nurse provides good oral hygiene (mouth care) using sterile water to prevent the drying effect of the oxygen therapy. Positioning the infant on the side helps maintain an open airway. Suctioning is used only as needed because there is risk of increased intracranial pressure and hypoxia.

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention? 1 To stimulate respiration 2 To assist in stimulating cardiac activity 3 To remove fluid from the lungs 4 To increase pulmonary blood flow

1 - To stimulate respiration Respiration in a newborn is stimulated by several chemical, mechanical, thermal, and sensory factors working together. Suctioning of the mouth and nose of the newborn stimulates the respiratory center. Thoracic squeezing in the newborn helps remove fluid from the lungs; however, suction helps remove the secretions from the upper respiratory tract. If cardiac activity is absent in the newborn, it can be stimulated by cardiopulmonary resuscitation. The pulmonary blood flow increases spontaneously once the newborn starts breathing.

The nurse is assessing a healthy newborn immediately after birth. Arrange the sequence of physiologic findings the nurse would observe during the first 4 hours of the newborn's birth. 1.Heart rate is 160 beats/minute. 2.Newborn passes meconium. 3.Appears to be pink in color. 4.Heart rate is 100 beats/minute.

1.Heart rate is 160 beats/minute. 3.Appears to be pink in color. After birth, newborns undergo various physiologic changes to get accustomed to the new environmental conditions. The major transitional changes occur during the first 8 hours after the birth. The first stage of the transition period lasts for 30 minutes and is the first period of reactivity after the birth. During this stage, the newborn's heart rate is usually 160 to 180 beats/minute to ensure rapid supply of blood. After 30 minutes, the heart rate reduces to 100 beats/minute. From 60 to 100 minutes after birth, the newborn either sleeps or shows reduced motor activity. During this time, the newborn has rapid respiration and appears to be pink in color. The newborn enters the second stage of transition 2 to 8 hours after birth, and in this phase the mucus production starts and the infant passes meconium.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. 1. Gently insert the NG tube through the mouth or nose 2. Check placement of the NG tube by aspirating gastric contents 3. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus 4. Lubricate the tip of the tube with sterile water

1.Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus 2.Lubricate the tip of the tube with sterile water 3.Gently insert the NG tube through the mouth or nose 4.Check placement of the NG tube by aspirating gastric contents The infant is placed in a supine position. The NG tube is measured from the tip of the nose to the earlobe and to midpoint between the xiphoid process and the umbilicus. Tape may be used to mark the correct length on the tube. The tip of the tube is lubricated with sterile water and then is inserted through the mouth or nose. Placement of the tube is checked by aspirating gastric contents.

What does the nurse include in the plan of care of a high risk preterm infant? Select all that apply. 1 Maintain room temperature 2 Assess for respiratory distress 3 Routinely monitor blood pressure 4 Assess intake and output records 5 Encourage skin-to-skin (kangaroo) contact

2 - Assess for respiratory distress 3 - Routinely monitor blood pressure 4 - Assess intake and output records 5 - Encourage skin-to-skin (kangaroo) contact The nurse routinely monitors the infant's blood pressure to assess whether the values are increasing normally in the first month of life. Accurate intake and output records are necessary to understand the infant's fluid status. The preterm infant is at risk for respiratory distress. Therefore the nurse needs to assess the infant's respiratory function so that prompt actions can be taken. The nurse encourages the parents to provide skin-to-skin (kangaroo) contact with the infant to maintain thermal stability. A preterm infant needs application of external warmth. The room temperature may not be effective to maintain thermal stability. Therefore the infant is placed in a heated environment to prevent cold stress.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. What should the nurse tell the parents to do? 1 Apply topical anesthetics with each diaper change 2 Expect a yellowish exudate to cover the glans after the first 24 hours 3 Apply constant pressure to the site if bleeding occurs and call the physician 4 Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes

2 - Expect a yellowish exudate to cover the glans after the first 24 hours Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. How should the nurse respond to this mother's concern? 1term-60 Telling the mother not to worry because breastfed babies have this type of stool 2 Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements 3 Asking the mother what she ate at her last meal 4 Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her

2 - Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. This type of stool is the first stool that all newborns have, not just breastfed babies. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

When caring for a newborn, the nurse must be alert for signs of cold stress, including what? 1 Decreased activity level 2 Increased respiratory rate 3 Hyperglycemia 4 Shivering

2 - Increased respiratory rate An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

The nurse is caring for a two-day-old term infant who was circumcised six hours ago. He is restless and fussy and refuses to breastfeed. The nurse attempts nonpharmacologic interventions with minimal results. What medication does the nurse expect the primary health care provider to order as an analgesic for the newborn? 1 Oral sucrose 2 Liquid acetaminophen 3 Intravenous (IV) fentanyl 4 Topical prilocaine-lidocaine (EMLA)

2 - Liquid acetaminophen Oral liquid acetaminophen is a nonopioid analgesic that may be used to reduce pain following circumcision. It may be administered every 4 hours, not to exceed 75 mg/kg/day. Oral sucrose may be given before circumcision along with 4% lidocaine as a topical anesthetic; it is not used to alleviate postcircumcision pain. Prilocaine-lidocaine (EMLA) is a local anesthetic applied topically prior to circumcision. Bolus or continuous IV infusion of opioids, like fentanyl, provide effective pain control with low incidence of adverse effects; however, these are most often used for more severe pain.

The nurse is providing postpartum care to a new mother who just gave birth. The new mother reports having a hard time getting her infant to "latch on" while breastfeeding. She expresses frustration with the process and asks the nurse whether breastfeeding has any real benefits. What can the nurse identify as benefits of breastfeeding? Select all that apply. 1 Increases time between feedings 2 Reduces the risk of the child having asthma 3 Reduces the risk of hypertension in the mother 4 Reduces the risk of the child getting type 1 diabetes 5 Increases bonding experience between mother and child

2 - Reduces the risk of the child having asthma 3 - Reduces the risk of hypertension in the mother 5 - Increases bonding experience between mother and child Breastfeeding has multiple benefits for the infant and the mother, including reducing the risk of the child having asthma, reducing the risk of hypertension in the mother, and increasing the bonding experience between the mother and child. Breastfeeding does not increase the time between feedings. Breastfeeding reduces the risk of the child getting type 2 diabetes, not type 1 diabetes.

Which TORCH infection could be contracted by the infant because the mother owned a cat? 1 Rubella 2 Toxoplasmosis 3 Varicella-zoster 4 Parvovirus B19

2 - Toxoplasmosis Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

Which instructions should the nurse include when teaching a mother about the storage of breast milk? Select all that apply. 1 Store milk in 8 to 12 oz containers. 2 Wash hands before expressing breast milk. 3 Store refrigerated milk in the door of the refrigerator. 4 Milk thawed in the refrigerator can be stored for 24 hours. 5 Place frozen milk in the microwave for only a few seconds to thaw.

2 - Wash hands before expressing breast milk. 4 - Milk thawed in the refrigerator can be stored for 24 hours. Breast milk storage guidelines for home use for full-term infants are: (1) Before expressing or pumping breast milk, wash your hands. (2) Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they can also be washed in a dishwasher. If the water supply may not be clean, boil containers after washing. Plastic bags designed specifically for breast milk storage can be used for short-term storage (less than 72 hours). (3) Write the date of expression on container before storing milk. A waterproof label is best. (4) Store milk in serving sizes of 2 to 4 ounces to prevent waste. (5) Storing breast milk in the refrigerator or freezer with other food items is acceptable. (6) When storing milk in a refrigerator or freezer, place containers in the middle or back of the freezer, not on the door. (7) When filling a storage container that will be frozen, fill only three quarters full, allowing space at the top of the container for expansion. (8) To thaw frozen breast milk, place container in the refrigerator for gradual thawing or under warm, running water for quicker thawing. Never boil or microwave. (9) Milk thawed in the refrigerator can be stored for 24 hours. (10) Thawed breast milk should never be refrozen. (11) Shake milk container before feeding baby and test the temperature of the milk on the inner aspect of your wrist. (12) Any unused milk left in the bottle after feeding is discarded.

The nurse is caring for a breastfeeding mother who is four weeks postpartum. The new mother asks the nurse about contraception that can be used while she is breastfeeding her infant. What is the nurse's best response? 1 "We recommend taking hormonal contraceptives that contain estrogen." 2 "A progestin-only pill is a good option for you considering the age of your baby." 3 "Using a condom is an effective way to prevent pregnancy while breastfeeding." 4 "You do not have to worry about contraception, because you cannot get pregnant while breastfeeding."

3 - "Using a condom is an effective way to prevent pregnancy while breastfeeding." Condoms and other barrier methods are effective forms of contraception for the breastfeeding mother and are safe to use because they do not impact the infant or affect milk supply. Hormonal contraceptives that contain estrogen are not recommended for breastfeeding women, as they affect milk supply. A progestin-only pill is not a good option since the infant is only 4 weeks old. Progestin-only pills, injections, and implants are not recommended until after six weeks postpartum. It is a myth that women cannot get pregnant while breastfeeding, so this statement is inaccurate.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are some generalized signs? 1 Hypertonia, tachycardia, and metabolic alkalosis 2 Hypertension, absence of apnea, and ruddy skin color 3 Abdominal distention, temperature instability, and grossly bloody stools 4 Scaphoid abdomen, no residual with feedings, and increased urinary output

3 - Abdominal distention, temperature instability, and grossly bloody stools Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric aspirates, and oliguria are signs of NEC. 86%of students nationwide answered this question correctly.

While assessing a 1-week-old infant, the nurse observes that the newborn has lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? 1 Heart rate of 120 beats/min 2 Body temperature of 99.5° F 3 Blood glucose level of 38 mg/dL 4 Blood pressure (BP) of 80/40 mm Hg

3 - Blood glucose level of 38 mg/dL Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dL of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dL (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120 beats/min, and BP of 80/40 mm Hg are normal values for a newborn and are not associated with the infant's manifestations.

The nurse observes that the lips, feet, and palms of a newborn are pale blue even 48 hours after birth. What can the nurse suspect from this observation about the newborn's clinical condition? 1 Acrocyanosis 2 Polycythemia 3 Central cyanosis 4 Transient tachypnea

3 - Central cyanosis When pale blue discoloration of the lips, feet, and palms of the newborn persists for more than 24 hours after birth, it is referred to as central cyanosis. Central cyanosis can be the result of an inadequate supply of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Transient tachypnea is a condition in which the newborn has difficulty breathing due to the obstruction of the nasal passage. If the newborn has polycythemia, the newborn's face would have a dark red complexion, but the newborn would not have pale blue lips, feet, and palms. Acrocyanosis is a condition in which the infant shows bluish discoloration of the hands and feet for about 24 hours after birterm-60th. Because the newborn in this scenario shows bluish discoloration 48 hours after birth, it indicates that the infant has central cyanosis and not acrocyanosis.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? 1 Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours 2 Wash off the yellow exudate that forms on the glans at least once every day to prevent infection 3 Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change 4 Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs

3 - Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change With each diaper change, the penis should be washed off with warm water, not prepackaged diaper wipes, to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day 2 Cut the nails while the baby is playing 3 Cut the nails while the baby is sleeping 4 Cut the nails while breastfeeding the baby 5 Cover the baby's hands with loose-fitting mitts

3 - Cut the nails while the baby is sleeping 5 - Cover the baby's hands with loose-fitting mitts The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.

Which statement provides helpful and accurate nursing advice concerning bathing the newborn? Select all that apply. 1 Bathe immediately after feeding while baby is calm and relaxed. 2 Only plain warm water can be used to preserve the skin's acid mantle. 3 Powders are not recommended because the infant can inhale powder. 4 Newborns should be bathed every day, for the bonding as well as the cleaning. 5 Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed.

3 - Powders are not recommended because the infant can inhale powder. 5 - Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Tub baths may be given as soon as an infant's temperature has stabilized. Powder is not recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.

Why is vitamin K given to the newborn? 1 To reduce bilirubin levels 2 To increase the production of red blood cells 3 To enhance ability of blood to clot 4 To stimulate the formation of surfactant

3 - To enhance ability of blood to clot Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant.

The primary health care provider instructs the nurse to give a hepatitis B (HepB) vaccine to a newborn. How should the nurse administer the vaccine? Select all that apply. 1 Through the deltoid muscle 2 Via the dorsogluteal muscle 3 Using the vastus lateralis muscle 4 By inserting the needle at a 60-degree angle 5 By inserting the needle at a 90-degree angle

3 - Using the vastus lateralis muscle 5 - By inserting the needle at a 90-degree angle The preferred injection site for a newborn is the vastus lateralis muscle in the thigh at a 90-degree angle. This is the best choice because this muscle has an adequate amount of muscle mass and fat. Administration of the hepatitis B (HepB) vaccine through the deltoid muscle is not recommended in infants, because this muscle has an inadequate amount of muscle for intramuscular (IM) administration. The dorsogluteal muscle is very small, poorly developed, and dangerously close to the sciatic nerve, which occupies a proportionately larger area in infants than in older children. Therefore it is not recommended as an injection site in newborns. The administration of the HepB vaccine is done by inserting the needle at a 90-degree angle, not at a 60-degree angle.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, what should nurses be aware of? 1 Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. 2 The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. 3 Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time. 4 Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) often are not detected until the child goes to school.

4 - Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) often are not detected until the child goes to school. Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

Newborns whose mothers are substance abusers frequently exhibit which behaviors? 1 Excessive sleep, weak cry, and diminished grasp reflex 2 Hypothermia, decreased muscle tone, and weak sucking reflex 3 Circumoral cyanosis, hyperactive Babinski reflex, and constipation 4 Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

4 - Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, hyperactive muscle tone, and uncoordinated sucking and swallowing behavior. They will have poor sleeping patterns, increased reflexes, and a high-pitched cry. They will have diarrhea, not constipation.

While caring for an infant, which method should the nurse adopt to prevent heat loss due to evaporation? 1 Wrap the infant in a cloth. 2 Place the infant in a warm crib. 3 Place the crib away from the windows. 4 Dry the infant immediately after the bath.

4 - Dry the infant immediately after the bath. The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min

4 - Heart rate of 70 beats/min The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.

Which is a priority nursing intervention when providing care for a high risk infant? 1 Touching the infant often 2 Providing enteral feeding 3 Encouraging breastfeeding 4 Helping the infant conserve energy

4 - Helping the infant conserve energy Nursing interventions should be implemented in a way that facilitates the conservation of energy in a high risk infant. The infant can then use this energy for growth and development. To prevent stress the nurse avoids touching the infant often. Enteral feeding may be contraindicated in some infants to prevent complications. Breastfeeding may not be possible in infants with respiratory distress syndrome, and therefore parenteral nutrition may be required.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. What are the tremors most likely the result of? 1 Seizures 2 Birth injury 3 Hypocalcemia 4 Hypoglycemia

4 - Hypoglycemia This infant is macrosomic and at risk for hypoglycemia. The tremors are jitteriness that is associated with hypoglycemia. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. Tremors are not associated with seizures, birth injury, or hypocalcemia.

The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise? 1 Cow's milk orally 2 Infant formula orally 3 Intravenous (IV) saline infusion 4 Intravenous (IV) dextrose infusion

4 - Intravenous (IV) dextrose infusion If the glucose levels are less than 25 mg/dL in the first 4 hours, or less than 35 mg/dL in the first 4 to 24 hours, it indicates hypoglycemia. All infants at risk for hypoglycemia should be fed within the first hour, with glucose testing performed 30 minutes after breastfeeding. If the glucose levels remain low despite feeding, IV dextrose is prescribed to the newborn. Cow's milk is generally not preferred for infants, because it may cause infections. Administration of infant formula is recommended in infants with hypocalcemia. IV saline infusion is not beneficial to hypoglycemic infants, because a saline infusion consists of plain salts and does not increase the glucose levels in the body.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action? 1 Notify the parents that their infant is not doing well 2 Continue to observe and make no changes until the saturations are 75% 3 Continue with the admission process to ensure that a thorough assessment is completed 4 Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify the physician

4 - Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify the physician Listening to breath sounds, ensuring the patency of the endotracheal tube, increasing oxygen, and notifying the physician are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%. The nurse should delay other tasks to stabilize the infant. Notifying the parents is not appropriate. Further assessment and intervention are warranted before determination of fetal status.

A mother of a newborn reports to the nurse that the child developed bluish pigmentation on the back. What could be the reason for this condition? 1 Infection 2 Hypothermia 3 Polycythemia 4 Mongolian spots

4 - Mongolian spots Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells (RBCs) on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, what should the nurse do? 1 Cover the probe with a nonreflective material 2 Place the thermistor probe on the left side of the chest 3 Recheck the temperature by periodically taking a rectal temperature 4 Prewarm the radiant heat warmer and place the undressed newborn under it

4 - Prewarm the radiant heat warmer and place the undressed newborn under it The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.

The nurse is planning the diet plan for a Korean postpartum patient. What food should the nurse include in the patient's diet plan to increase the production of breast milk? 1 Corn syrup 2 Clarified butter 3 Boiled chicken 4 Seaweed soup

4 - Seaweed soup Seaweed soup is preferred by Korean patients after delivery to increase milk production. Some cultures believe that clarified butter will clear out meconium. Corn syrup solids are added to infant formula to increase carbohydrate levels. Hmong patients prefer boiled chicken as the part of their diet in the first month after birth.

With regard to umbilical cord care, what should nurses be aware of? 1 The stump can easily become infected. 2 The cord clamp is removed at cord separation. 3 The average cord separation time is 5 to 7 days. 4 A nurse noting bleeding from the vessels of the cord should immediately call for assistance.

1 - The stump can easily become infected. The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

What would a newborn male, estimated to be 39 weeks of gestation, exhibit? 1 Extended posture when at rest 2 Testes descended into the scrotum 3 Abundant lanugo over his entire body 4 Ability to move his elbow past his sternum

2 - Testes descended into the scrotum A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn's good muscle tone will result in a more flexed posture when at rest. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. What should be parents taught to do? 1 Avoid use of pacifiers 2 Use a rear-facing car seat 3 Use a crib with side rail slats that are no more than 3 inches apart 4 Place the newborn on the abdomen (prone) after feeding and for sleep

2 - Use a rear-facing car seat The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until exceeding the car seat's limits for height and weight. The prone position is no longer recommended because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Slats in a crib should be no more than 2 inches apart.

What is the basic mechanism for heat generation in newborns? 1 Vasodilation 2 Shivering thermogenesis 3 Metabolism of brown fat 4 Metabolism of carbohydrates

3 - Metabolism of brown fat Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing the heat production as much as 100%. Vasodilation is a response to excess heat and causes dissipation of heat. Shivering thermogenesis is the mechanism of heat conservation in adults. Heat generation usually occurs by lipid metabolism and not by carbohydrate metabolism.

Which dietary instruction does the nurse give to the parents of a child with phenylketonuria? 1 "Use artificial sweeteners instead of sugar." 2 "Include breads and hamburgers in child's diet." 3 "Include fruits and vegetables in the child's diet." 4 "Avoid meat and dairy products in the child's diet."

4 - "Avoid meat and dairy products in the child's diet." Meat and dairy products contain high protein levels, which increase phenylalanine levels. Therefore the nurse instructs the patient to eliminate these foods from the child's diet. Telling the patients to include any fruits and vegetables in the diet will be unsafe because some fruits may have high phenylalanine levels. Therefore the nurse needs to provide the patient with a proper food list. Artificial sweeteners are not safe for a child because they contain phenylalanine. Breads and hamburgers have low phenylalanine levels. However, they need to be measured to prevent high amounts of phenylalanine in the blood.

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________. Record your answer as a whole number.

9 The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis.