Nursing Care of the Newborn
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action would the nurse take? 1. Rewarm gradually. 2. Notify the practitioner. 3. Assess for hyperglycemia. 4. Record skin temperature hourly.
1. Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.
Which is the most important nursing action when caring for a client who has a newborn with a neurological impairment? 1. Assisting the client with the grieving process 2. Performing frequent neurological assessments of the newborn 3. Arranging for social services to discuss possible placement of the newborn 4. Obtaining a prescription for an antidepressant to help the client cope with the depressing news
1. Grieving is expected and necessary whenever a newborn is born less than healthy. More information is needed to conclude that frequent neurological assessments are warranted; the frequency of assessments depends on the severity and type of the neurological problem. Arranging for social services to discuss possible placement of the newborn may be done later; however, it is not the priority at this time. Obtaining a prescription for an antidepressant to help the client cope with the depressing news could result in a delay in the client's ability to actively participate in dealing with feelings.
A newborn with a severe bilateral cleft lip and palate is shown to the father. The father says, "How could this happen to us? My wife is going to be so upset!" Which is the best response by the nurse? 1. "This must be very hard on you. I can go with you when your wife sees the baby." 2. "You have a healthy baby, and the clefts can be closed so they won't be noticeable." 3. "This feeling won't last. Soon you'll love your baby so much that you won't even notice the clefts." 4. "I know this is difficult for you, but you can't think of yourself now, because your wife needs you to be strong."
1. Identifying feelings ("This must be very hard on you") and providing support ("I can go with you when your wife sees the baby") during stressful times are ways of demonstrating concern during a crisis. Telling the father that the clefts can be closed so they won't be noticeable or that the feeling won't last is not a supportive or insightful reply. Telling the father that he can't think of himself now is an inappropriate reply that may instill guilt feelings; the father and the mother need support through this crisis.
Which factor contributes to the development of physiological jaundice in a newborn? 1. Immature liver function 2. An inability to synthesize bile 3. An increased maternal hemoglobin level 4. A high hemoglobin and low hematocrit level
1. Jaundice occurs because of the expected physiological breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.
When calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate? 1. Muscle tone 2. Amount of mucus 3. Degree of head lag 4. Depth of respirations
1. Muscle tone The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score.
Which assessment finding in a newborn of 33 weeks' gestation alerts the nurse to notify the health care provider? 1. Flaring nares 2. Acrocyanosis 3. Heartbeat of 140 beats/min 4. Respirations of 40 breaths/min
1. Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and to increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the newborn.
When is it not necessary for the nurse to wear gloves while caring for a newborn? 1. Offering a feeding 2. Changing the diaper 3. Giving an admission bath 4. Suctioning the nasopharynx
1. Standard precautions do not include the use of gloves for feeding. Wearing clean gloves for diaper changes of newborns is standard protocol. Clean gloves should be worn for all admission baths, because the nurse will be exposed to blood and amniotic fluid. Clean gloves should also be worn while the nurse suctions an infant.
Which characteristic that may pose a potential nutrition problem would the nurse identify in a preterm neonate? 1. Inadequate sucking reflex 2. Diminished metabolic rate 3. Rapid digestion of formula 4. Increased absorption of nutrients
1. The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting. The metabolic rate is increased because of fatigue and growth needs. The digestive process is slow, especially in regard to the ability to digest lipids. Absorption of nutrients is decreased because the gastrointestinal tract is immature.
A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1. The ribcage is not compressed and released during birth. 2. The sudden temperature change at birth causes aspiration. 3. There is usually oxygen deprivation after a cesarean birth. 4. There is no gravity during the birth to promote drainage from the lungs.
1. The release after compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.
How would the nurse best explain the probable cause of jaundice to the parents of a 3-day-old newborn? 1. An allergic response to the feedings 2. The body is slow to get rid of the fetal red blood cells that have been destroyed 3. A temporary bile duct obstruction commonly found in newborns 4. The seepage of maternal Rh-negative blood into the neonate's bloodstream
2. After birth, fetal erythrocytes hemolyze, releasing bilirubin into the circulation; the immature liver cannot metabolize the bilirubin as rapidly as it is produced, resulting in physiological jaundice. Jaundice is not an allergic response; it is a physiological destruction of fetal red blood cells. Bile duct obstruction, which is not common in newborns, is not the cause of the jaundice. The newborn and mother have independent circulations, and Rh-negative blood does not enter the fetus's bloodstream. A problem may occur if the mother is sensitized, because her antibodies can enter the fetal circulation.
During a newborn assessment the nurse identifies the absence of the red reflex in the eyes. Which would the nurse's next action be? 1. Rinse the eyes with sterile saline. 2. Notify the primary health care provider. 3. Expect eye edema to subside within a few days. 4. Conclude that this is a result of the prescribed eye prophylaxis.
2. An absence of the red reflex may be indicative of congenital cataracts, and the primary health care provider should be notified. The red reflex is elicited by shining the light of an ophthalmoscope into the newborn's eyes, which should produce a reddish circle. Rinsing the eyes will not affect the red reflex. The red reflex or its absence is not related to edema, which may occur after eye prophylaxis, or to eye prophylaxis itself.
Which nursing action best promotes parent-infant attachment with a newborn who is being transferred to a regional neonatal intensive care unit because of respiratory distress? 1. Encouraging the parents to call their infant by name 2. Allowing the parents to hold their infant before departure 3. Giving the parents a picture of their infant in the intensive care unit 4. Instructing the parents to contact the neonatal intensive care unit daily
2. Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant's progress.
Which is prevented by providing warm, humidified oxygen to a preterm infant? 1., Apnea 2., Cold stress 3. Respiratory distress 4. Bronchopulmonary dysplasia
2. By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.
A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem would the nurse anticipate when planning care for this infant? 1. Anemia 2. Hypoglycemia 3. Protein deficiency 4. Calcium deficiency
2. Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary health care provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.
Which information would the nurse include to best assist new parents in understanding the unique characteristics of their newborn? 1. Typical auditory and visual acuity 2. Expected movements and behaviors 3. The need for parent-infant attachment 4. The need to establish a feeding schedule
2. Information on expected movements and behaviors helps parents understand the unique features of their newborn and promotes interaction and appropriate care. A discussion of auditory and visual acuity is too limited; the parents need a broader discussion of infant behaviors. Although parent-infant attachment is important, this can best be fostered if parents know what behaviors to expect from their infant. The need to establish a feeding schedule is too limited; in addition, most infants are on a demand feeding schedule, which fosters individuality.
Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? 1 Touching the infant's cheek 2. Striking the surface of the infant's crib suddenly 3. Allowing the infant's feet to touch the surface of the crib 4. Stroking the sole of the foot along the outer edge from the heel to the toe
2. Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.
Which procedure would the nurse expect to be performed on a neonate that may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis? 1. Heel stick 2. Buccal smear 3. Urinary catheterization 4. Venous blood withdrawal
2. The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine or venous blood may be used to assess chromosomal aberrations but is not definitive for the newborn.
Which intervention would the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? 1. Fast-acting insulin 2. Special high-risk care 3. Routine newborn care 4. Limited glucose intake
2. The infant of a diabetic mother is a newborn at risk because of the interaction between the maternal disease and the developing fetus. The newborn of a mother with type 1 diabetes generally is hypoglycemic because of oversecretion of insulin by the newborn's hypertrophied pancreas. The newborn of a mother with type 1 diabetes is at high risk and requires intensive care. The newborn of a mother with type 1 diabetes is prone to hypoglycemia and will probably need increased glucose.
The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? 1. Develop a basic teaching plan. 2. Ask the mother if she understands. 3. Observe the mother feeding the infant. 4. Determine the mother's readiness to learn.
3. A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.
Which information concerning a safe feeding technique would the nurse provide to a mother whose newborn infant son has a cleft lip and palate? 1. "Because he tires easily, it's best to have him lying in bed while he is being fed." 2. "Hold him in a horizontal position and feed him slowly to help prevent aspiration." 3. "Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air." 4. "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion."
3. Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.
Which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area? 1. Remove the cord clamp only after the cord stump has separated. 2. Smooth ointment or baby lotion around the cord after the sponge bath. 3. Leave the area untouched or clean with soap and water; then pat it dry. 4. Wrap an elastic bandage snugly around the waist area over the cord site.
3. Healing is optimal when the area is left alone or, if needed, is washed with mild soap and water and then gently dried. The cord clamp is removed when the cord stump is dry, usually at 24 hours. Ointment and other emollients will keep the cord moist; rapid drying of the cord is preferred. Wrapping an elastic bandage snugly around the waist area over the cord site prevents the cord from drying and provides a dark, warm, moist medium for the growth of organisms.
Which intervention will be delayed until the newborn is 36 to 48 hours old? 1. Vitamin K injection 2. Test for blood glucose level 3. Screening for phenylketonuria 4. Test for necrotizing enterocolitis
3. In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test.
The nurse is assessing a newborn with exstrophy of the bladder. Which other defect is often associated with exstrophy of the bladder and may be of concern to the nurse? 1.Absence of one kidney 2. Congenital heart disease 3. Pubic bone malformation 4. Tracheoesophageal fistula
3. Incomplete formation of the pubic bone is often associated with exstrophy of the bladder. Absence of one kidney, congenital heart disease, and tracheoesophageal fistula are not associated with exstrophy of the bladder.
Which method of swaddling could cause risk for injury? 1. Knees flexed 2. Arms flexed 3. Legs extended 4. Arms extended
3. Legs Extended Swaddling an infant tightly with the legs extended is associated with an increased risk for hip dislocation. The correct way to swaddle an infant is with the hips in slight flexion and abducted and allowing for freedom of movement of the knees. Swaddling the infant with the arms either flexed or extended does not place the newborn at risk for injury.
While a mother is inspecting her newborn, she expresses concern that her baby's eyes are crossed. Which response by the nurse is appropriate? 1. "Take another look. They seem fine to me." 2. "It's all right. Most babies have crossed eyes." 3. "This is expected. Your baby is trying to focus." 4. "You're right. I'll contact your health care provider."
3. Newborns' eye movements are uncoordinated, and the eyes may appear crossed as they attempt to focus. As the eye muscles mature, the apparent strabismus disappears. Stating that the baby's eyes seem fine discounts the mother's concern and is demeaning. Although it is true that the baby's eyes are crossed, the mother should be given an explanation for the apparent strabismus. Telling the mother that she is right and that the health care provider must be contacted is misinformation that will increase the mother's anxiety.
The nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment finding supports this suspicion? 1. Lethargy and constipation 2. Grunting and low-pitched cry 3. Irritability and nasal congestion 4. Watery eyes and rapid respirations
3. Opioid withdrawal affects the central nervous system and respiratory system, resulting in irritability and nasal congestion. Lethargy and constipation may occur in a newborn with thyroid deficiency. Grunting and a low-pitched cry may indicate that the newborn is experiencing cold stress or respiratory distress. Watery eyes and rapid respirations may occur in a newborn affected with syphilis.
The nurse is teaching a prenatal class regarding infant safety. Which statement made by a future parent indicates effective teaching? 1. "My mother has already made the cutest pillowcases for the baby's pillows." 2. "I just bought a new baby seat that can be strapped into the front seat of the car." 3. "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." 4. "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."
3. Research demonstrates that placing an infant on the back reduces the incidence of sudden infant death syndrome (SIDS). Pillows in an infant's crib can cause suffocation. It is unsafe to strap an infant seat into the front seat of a car. An infant can drown in a very small amount of water in a tub; it is unsafe to leave an infant alone in a tub.
Which assessment finding would the nurse expect to find in a newborn with a diaphragmatic hernia? 1. Diarrheal stools 2. Enlarged abdomen 3. Barrel-shaped chest 4. Abdominal breath sounds
3. The chest is barrel shaped because of the protrusion of abdominal viscera through the defect into the thoracic cavity. Diarrhea is not associated with a diaphragmatic hernia; usually there is colicky pain and constipation. The abdomen is markedly scaphoid (sunken). There are no breath sounds over the abdomen.
The nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? 1. Muscle irritability within 1 hour of birth 2. Neurologic signs during the first 24 hours 3. Jaundice that develops in the first 12 to 24 hours 4. Jaundice that develops between 48 and 72 hours after birth
3. The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL (100 mcmol/L) the second to third day when jaundice appears (physiologic jaundice).
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. Which would the nurse's initial intervention be? 1. Report this finding. 2. Administer nasal oxygen. 3. Lower the head of the bassinet. 4. Remove secretions from the pharynx.
4. An increase in mucus production is expected during the second reactive period; secretions should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinet may help secretions drain, the newborn cannot remove secretions that block respirations.
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent? 1. Radiation 2. Convection 3. Conduction 4. Evaporation
4. Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.
When checking the reflexes of a newborn born vaginally in the breech presentation, the nurse is unable to elicit a specific reflex response. The absence of this reflex is not uncommon in neonates born with this presentation. How would the nurse attempt to elicit this response? 1. Moving the thumb along the sole of the foot 2. Stroking the ulnar surface of the hand and fifth finger lightly 3. Touching the skinfold of the mouth and cheek on the same side 4. Holding the infant in the upright position while pressing the feet flat on the
4. Holding the infant in the upright position while pressing the feet flat on the crib mattress elicits the stepping response, which is absent when paresis is present and in neonates born vaginally in the breech presentation. Moving the thumb along the sole of the foot should elicit the Babinski reflex, which is unrelated to a vaginal breech birth. Stroking the ulnar surface of the hand and fifth finger lightly should elicit the digital response reflex, which is unrelated to a vaginal breech birth. Touching the skinfold of the mouth and cheek on the same side should elicit the rooting response reflex, which is unrelated to a vaginal breech birth.
A full-term infant who is large for gestational age (LGA) should be monitored for which risk? 1. Hypotension 2. Hypothermia 3. Hypocalcemia 4. Hypoglycemia
4. Infants that are LGA are considered at risk for hypoglycemia, and their glucose should be monitored following a protocol. LGA infants are not at an increased risk for hypotension, hypothermia, or hypocalcemia.
The nurse is caring for a preterm infant who is receiving oxygen therapy. Which would the nurse do to prevent retinopathy of prematurity (ROP)? 1. Cover the neonate's eyes with a shield. 2. Place the neonate in an elevated side-lying position. 3. Assess the neonate every hour with a pulse oximeter. 4. Support the neonate's oxygen saturation while providing minimal FiO2
4. ROP is a complex disease of the preterm infant; hyperoxemia is one of the numerous causes implicated. Oxygen therapy is maintained at the lowest level necessary to support respiratory status. If the oxygen concentration needs to be increased to maintain life, ROP may not be preventable. Using a shield over the neonate's eyes will not prevent the development of ROP, nor does positioning or assessment of the neonate every hour with a pulse oximeter alone. If the pulse oximetry results are within an acceptable range, the oxygen concentration may be reduced.
A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How would the nurse best respond? 1. "A healthy newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2. "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3. "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4. "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mother during pregnancy, so the glucose level may drop."
4. The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.
A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How would the nurse respond when the mother asks what is wrong? 1. "You seem very concerned. I don't see anything unusual." 2. "Your baby appears to have a problem. I'll notify the pediatrician." 3. "The swelling and discharge will go away. It's nothing to worry about." 4. "The swelling and discharge are expected. They're a response to your hormones."
4. The response "The swelling and discharge are expected. They're a response to your hormones." emphasizes that the findings are to be expected and explains why they occur; this may relieve the client's anxiety. Claiming not to see anything unusual denies that there is anything to explain to the mother and is somewhat belittling. Calling the pediatrician is not necessary; these findings are expected. The comment that the swelling and discharge will go away tells the mother that the findings are expected but provides no explanation and is somewhat belittling.
How would an Apgar score recorded 5 minutes after birth assist the nurse in evaluating the care of the newborn? 1. Gestational age of the newborn 2. Effectiveness of the birthing process 3. Possibility of respiratory distress syndrome 4. Adequacy of the transition to extrauterine life
4. The score at 5 minutes indicates the adequacy of the cardiac and respiratory systems' response to the environment. The Dubowitz score is related to gestational age. The Apgar score represents the neonate's response to the environment and is not related to the actual process of labor and birth. The Apgar score is not a diagnostic tool for respiratory distress syndrome.
A newborn is found to have a diaphragmatic hernia. Which is the immediate intervention after the neonate is admitted to the neonatal intensive care unit? 1. Hydrating the infant with isotonic enemas 2. Limiting formula feedings to small amounts 3. Placing the infant in the Trendelenburg position 4. Providing gastric decompression via nasogastric tube
4. When a diaphragmatic hernia is present, intra-abdominal pressure must be minimized; this is accomplished with the use of gastric decompression. Hydrating the infant with isotonic enemas is not beneficial. These infants are not fed orally; intravenous fluids are given with careful measurement of electrolytes and intake and output to guide replacement therapy. The Trendelenburg position is contraindicated; the abdominal organs will increase pressure on the diaphragm.
The nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?
An audible click on abduction As the head of the femur moves within the acetabulum, sometimes there is an audible click when there is developmental dysplasia of the hip. Dorsiflexion followed by fanning is associated with the Babinski test. Hypertonia and jitteriness are neurological findings. An arched back and crying are signs of opisthotonic posturing.
The nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse identify?
Tonic Neck Reflex The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month. The Moro reflex is exhibited when a sudden change in equilibrium causes extension and abduction of the extremities followed by flexion and adduction. The Babinski reflex is exhibited when the examiner runs a finger up the lateral (small toe side) undersurface of the foot from the heel to the toes and then across the ball of the foot; the toes separate and flare out in response. The palmar grasp reflex is exhibited when the fingers flex around a person's finger placed in the infant's palm.
After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" How would the nurse respond?
"It's expected, and it's called vernix caseosa." Vernix caseosa, a cheeselike substance that protects the skin, is secreted by the fetus's skin toward the end of pregnancy. Thrush is an oral fungal infection caused by Candida albicans; usually it is acquired during the birth process. Milia are distended tiny sweat (eccrine) glands that look like whiteheads on the infant's nose; they disappear without special care. Telangiectatic nevi (stork bites, capillary hemangiomas) are pinkish-red, easily blanched spots that may appear on the upper eyelids, nose, upper lip, lower occiput, and nape of the neck; they have no clinical significance and fade between the first and second years of age.
Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. 1. Infection 2. African-American race 3. Prematurity 4. Breast-feeding 5 Formula feeding 6. Maternal diabetes
1, 3, 4 & 6 Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Newborns of East Asian race have a higher risk factor than African-Americans to develop jaundice. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.
Which characteristic would the nurse anticipate in an infant born at 32 weeks' gestation? 1. Barely visible areolae and nipples 2. Ear pinnae that spring back when folded 3. Definite creases of the infant's palms and soles 4. A zero-degree angle on the square window sign
1. Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant at 40 to 42 weeks' gestation.
Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct. 1. Crying 2. Tachypnea 3. Diaphoresis 4. Tachycardia 5. Hypertension
1. Crying Crying is a behavioral response. Tachypnea, diaphoresis, tachycardia, and hypertension are physiological responses to pain.
Which would be included in a plan of care to limit the development of hyperbilirubinemia in the breast-fed neonate? 1. Encouraging more frequent breast-feeding during the first 2 days 2. Instituting phototherapy for 30 minutes every 6 hours for 3 days 3. Substituting formula feeding for breast-feeding on the second day 4. Supplementing breast-feeding with glucose water during the first day
1. More frequent breast-feeding stimulates more frequent evacuation of meconium, thereby preventing resorption of bilirubin into the circulatory system. Phototherapy is the treatment for hyperbilirubinemia, and it is maintained continuously; it does not prevent the development of hyperbilirubinemia. It is not necessary to feed the infant formula because early breast-feeding tends to keep the bilirubin level low by stimulating gastrointestinal activity. Increasing water intake does not limit the development of hyperbilirubinemia, because only small amounts of bilirubin are excreted by the kidneys.
Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? 1. Duration of cry 2. Respiratory distress 3. Frequency of voiding 4. Poor nutritional intake
2. Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. If the infant is in respiratory distress, the nutritional intake is not important.
At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. Which is the nurse's priority action in response to this situation? 1. Stimulate crying. 2. Substitute sterile water for the formula. 3. Suction and then oxygenate the newborn. 4. Stop the feeding momentarily and then restart it.
3. Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed. Crying may add to the distress. Water could be aspirated, worsening the problem. Stopping the feeding momentarily and then restarting it is unsafe; the newborn is showing signs of a blocked airway.
Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? 1. Good cry 2. Grimace 3. Absent respiration 4. Slow, weak cry
4. A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system.
Which is the focus of nursing care for a newborn with respiratory distress syndrome? 1. Tapping the toes to stimulate respirations 2. Turning the infant frequently to prevent apnea 3. Maintaining oxygen concentration at 40% to support respiration 4. Keeping the infant warm to maintain body temperature at 98°F (37°C)
4. A warm environment is most important, because if the neonate has to maintain body temperature it will further compromise physical status by increasing metabolic activity and oxygen demand. Frequent turning and stimulation such as tapping the toes are both contraindicated, because increased activity increases oxygen demands. The oxygen percentage will vary with the neonate's Po2 values; the concentration of oxygen should never be set at a fixed amount.
A newborn's Apgar score at 5 minutes is 5. Which condition correlates with this low Apgar score? 1. Cerebral palsy 2. Genetic defects 3. Neurodevelopmental disorders 4. Neonatal morbidity
4. An Apgar score of 5 at 5 minutes is related to neonatal morbidity and mortality; by 5 minutes the healthy neonate is relatively stable, and the expected Apgar score is 8 to 10. The presence of cerebral palsy is not related to the Apgar score. It is rarely diagnosed in the newborn. Genetic defects may or may not be apparent at this time and are not related to the Apgar score. Neurodevelopmental disorders have not been proven to be correlated with the Apgar score, although research continues in this area.
The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which? 1. Early rooming-in 2. Taking-in behaviors 3. Taking-hold behaviors 4. Parent-child attachment
4. There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychological behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychological behavior described by Rubin that occurs after the third postpartum day.
A male infant is born at 28 weeks' gestation weighing 2 lb 12 oz (1247 g). Which finding would the nurse expect to note when performing an assessment? 1. Staring eyes 2. Absence of lanugo 3. Descended testicles 4. Transparent red skin
4. Transparent red skin is expected because of the absence of subcutaneous fat tissue. Preterm infants born nearer to term have open, staring eyes. Preterm infants are generally born with large amounts of lanugo, which begins to thin just before term and by 40 weeks is found only on the shoulders, back, and upper arms. The preterm infant's scrotum is small, and the testicles are usually high in the inguinal canal.
Which stool finding would the nurse anticipate in a breastfed neonate? Select all that apply. One, some, or all responses may be correct. 1. Pale yellow 2. Light brown 3. Offensive odor 4. Firm consistency 5. Pasty consistency
5. The breastfed neonate would have stool of a pasty consistency. Bottle-fed infants typically have stool that is pale yellow to light brown in color with an offensive odor and firm consistency.
Which adverse effect would the nurse monitor for after administering vitamin K to a newborn? Select all that apply. One, some, or all responses may be correct. 1. Pain 2. Edema 3. Jaundice 4. Erythema 5. Hemolysis
ALL Adverse reactions associated with vitamin K injections rarely occur, but can include pain at the injection site, edema, and erythema. Jaundice, hemolysis, and hyperbilirubinemia have also been reported, particularly in preterm infants.
Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct. 1. Stridor 2.Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting
ALL Findings indicative of abnormal breathing in newborns include stridor, mottling, bradypnea, nasal flaring, and expiratory grunting.
Which is the optimal area for the nurse to assess adequate tissue oxygenation in an African-American neonate?
Lack of skin pigmentation on the surfaces of the mucous membranes makes this the best area in which to assess this neonate's tissue oxygenation. Heels and buttocks are usually highly pigmented areas, and the buttocks often have Mongolian spots. The tips of the ears will indicate skin color later in life. Because most neonates' hands and feet exhibit acrocyanosis, the nail beds may be cyanotic as well.
The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants?
Lack the subcutaneous fat that usually provides insulation Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and has little of this insulating layer. The preterm infant has a relatively larger surface area per body weight than does a term infant. Preterm infants do not shiver or perspire. Depressed antibody production is unrelated to maintenance of body temperature.
A client asks about the difference between cow's milk and breast milk. The nurse would respond that cow's milk differs from human milk in that it contains which?
More protein, more calcium, and fewer carbohydrates Cow's milk contains more protein, more calcium, and fewer carbohydrates. Cow's milk is more difficult to digest because it is meant to meet a calf's, not an infant's, nutritional needs.
The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy?
Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.
How would the nurse elicit the Babinski reflex when assessing a full-term newborn?
Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Jarring the crib produces a startle response (Moro reflex); the legs and arms extend and the fingers fan out, and the thumb and forefinger form a C. Applying pressure against the soles of the feet produces the magnet reflex; the legs extend in response to the pressure on the soles of the feet. Having the feet touch the surface of the crib produces the stepping reflex; one foot is placed before the other in a simulated walk, with the weight on the toes.
Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?
The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.
Which would the nurse expect to observe in a healthy newborn's cord vessels?
Three vessels: one vein and two arteries The umbilical cord contains three vessels; one vein carries oxygenated blood to the fetus, and two arteries return deoxygenated blood to the placenta. A cord with two vessels may be associated with congenital abnormalities. If an infant has four vessels: two veins and two arteries, the infant has a cord anomaly.
Where would the nurse find the area of involvement associated with parietal swelling?
on top of the skull The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.
A client gives birth to a full-term male with an 8/9 Apgar score. Which would be included in the immediate nursing care of this newborn? 1. Drying him off, assessing respirations, and identifying him 2. Applying an antibiotic to the eyes, administering vitamin K, and bathing him 3. Aspirating the oropharynx, rushing him to the nursery, and stimulating him 4. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him
1. Drying him off, establishing a patent airway, and identifying the newborn are the priorities. Application of eye prophylaxis and administration of vitamin K are often delayed to allow the parents to bond with the infant; a bath at this time will increase the risk of cold stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready to hold him are not the priority care for a newborn.
The nurse is differentiating between cephalhematoma and caput succedaneum. Which finding is unique to caput succedaneum? 1. Edema that crosses the suture line 2. Scalp tenderness over the affected area 3. Edema that increases during the first day 4. Scalp over the area becomes ecchymosed
1. Edema that crosses the suture line is the sign that differentiates these two conditions; cephalhematoma does not extend beyond the suture line. Pain or tenderness is not associated with either condition. Edema that increases during the first day of life is unusual; it should shrink. Bruising may occur with either condition.
