[OB-2] Chapter 27 - The Newborn at Risk: Birth-Related Stressors

The nurse assesses that a newborn's skin has a ruddy appearance and the peripheral pulses are decreased. The nurse suspects polycythemia. Which lab report might indicate that the newborn has polycythemia? 1. Central venous hematocrit level greater than 65% 2. Bilirubin level of 6 mg/dl 3. Venous hemoglobin level lower than 12 g/dl 4. Blood glucose level of 44 mg/dl

Correct Answer: 1 Rationale 1: A venous hematocrit level greater than 65% indicates polycythemia. Rationale 2: This bilirubin level is within normal limits. Rationale 3: A venous hemoglobin level lower than 12 g/dl indicates anemia. Rationale 4: This blood glucose level is within normal limits.

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98°F

Correct Answer: 1 Rationale 1: Jitteriness of the newborn is associated with hypoglycemia, and would require close monitoring of blood glucose levels. Rationale 2: Sucking on the fingers is a normal finding. Rationale 3: A lusty cry is a normal finding. Rationale 4: An axillary temperature of 98°F is a normal finding.

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature. 2. Bilirubin level of 14 mg/dl 3. Decreased reflexes 4. Skin blanching yellow

Correct Answer: 1 Rationale 1: Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. Rationale 2: Bilirubin levels of 6 mg/dl or less would be considered therapeutic. Rationale 3: Reflexes during phototherapy should be normal, not decreased. Rationale 4: Yellowing in the skin should disappear with effective phototherapy.

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require: 1. Initial resuscitation. 2. Vigorous stimulation at birth. 3. Phototherapy immediately. 4. An initial feeding of iron-enriched formula.

Correct Answer: 1 Rationale 1: Newborns who have aspirated meconium might require resuscitation to establish adequate respiratory effort. Rationale 2: Stimulation at birth should be avoided to minimize respiratory movements. Rationale 3: Phototherapy is not required immediately. Rationale 4: Typically, bilirubin levels rise after the first 24 hours of life. Oral feedings may be withheld until respirations are normal. The newborn might require intravenous fluids.

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, the nursing instructor tells the students to: 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate.

Correct Answer: 1 Rationale 1: The friction from vigorous rubbing produces local heat, which aids in vasodilation and helps to decrease falsely high values. Rationale 2: A microlance is used to make the puncture in an unpunctured site. Rationale 3: The heel should not be cooled. Rationale 4: A microlance, not a needle, is used to make the puncture.

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine-specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.

Correct Answer: 1 Rationale 1: This action is correct; urine concentration as indicated by rising urine-specific gravity indicates a need for additional fluids. Rationale 2: Eyes should be covered at all times. Rationale 3: Six hours is too long; the temperature should be assessed every 4 hours to prevent hyper- or hypothermia. Rationale 4: The infant's care should be clustered to keep the infant under the lights as much as possible. The diaper should be changed while the infant is under the lights in the isolette.

During newborn resuscitation, the nurse evaluates the effectiveness of bag-and-mask ventilations by: 1. The rise and fall of the chest. 2. Sudden wakefulness. 3. Urinary output. 4. Adequate thermoregulation.

Correct Answer: 1 Rationale 1: With proper resuscitation, effectiveness is observed by visualizing the rise and fall of the chest. Rationale 2: Sudden wakefulness is not associated with effectiveness of bag-and-mask ventilations. Rationale 3: Urinary output is not associated with effectiveness of bag-and-mask ventilations. Rationale 4: Adequate thermoregulation is not associated with effectiveness of bag-and-mask ventilations.

Which findings would the nurse expect when assessing a newborn infected with syphilis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age

Correct Answer: 1,2,3 Rationale 1: Rhinitis is evident in the newborn exposed to syphilis. Rationale 2: Fissures on mouth corners and an excoriated upper lip indicate exposure to syphilis. Rationale 3: A red rash around the mouth and anus is observed. Rationale 4: The newborn is typically irritable with generalized edema, particularly over joints, and painful extremities. Rationale 5: The newborn is typically small for gestational age, and failure to thrive is common.

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs' test 5. Cord serum OgM

Correct Answer: 1,2,3,4 Rationale 1: The total blood hemoglobin primarily depends on the number of circulating RBCs. Rationale 2: Anemia is the reduction of red blood cells and/or hemoglobin concentration. Rationale 3: This test is an index of the production of mature red blood cells by the bone marrow. Rationale 4: The direct Coombs' test reveals the presence of antibody-coated Rh-positive red blood cells in the newborn. Rationale 5: These levels are not related to anemia.

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.

Correct Answer: 1,2,4,5 Rationale 1: Being able to keep the halogen lights on all the time is an important advantage. Rationale 2: The eyes do not have to be covered with this system. Rationale 3: The lights can stay on all the time. Rationale 4: One benefit of the fiber optic blanket is that the newborn is not overheated. Rationale 5: Weight loss is not a complication of this system.

Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding

Correct Answer: 1,3,4,5 Rationale 1: If nonreassuring fetal status is present, appropriate measures should be taken to deliver the fetus immediately. Rationale 2: During labor, a fetal pH of 7.25 or higher is considered normal. Rationale 3: Suctioning after delivery will be necessary so that the newborn does not aspirate meconium and mucus into the lungs. Rationale 4: The premature infant is at risk for respiratory problems because the lungs are not fully mature or ready to take over the processing of oxygen and carbon dioxide until 37-38 weeks' gestation. Rationale 5: Intrapartum bleeding can cause the newborn to require oxygen and resuscitation.

When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema

Correct Answer: 1,3,4,5 Rationale 1: Respiratory distress syndrome is due to alterations in surfactant quantity, composition, function, and production. Surfactant is required to maintain alveolar stability. Rationale 2: Respiratory acidosis, not alkalosis, occurs related to the increased PCO2 and decreased pH that result from alveolar hypoventilation. Rationale 3: When cells lack oxygen, there is an increase in lactate levels, a base deficit, and a decrease in pH, which is acidosis. Rationale 4: Upon expiration, the instability increases the atelectasis, which causes hypoxia and acidosis because of the lack of gas exchange. Rationale 5: Opacification of the lungs on x-ray might be due to massive atelectasis, diffuse alveolar infiltrate, or pulmonary edema.

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.

Correct Answer: 1,3,4,5 Rationale 1: The nurse will assist in obtaining skin cultures. Rationale 2: The nurse will encourage the parents to visit. Rationale 3: The nurse will evaluate bilirubin levels. Rationale 4: The nurse will administer oxygen as ordered. Rationale 5: The nurse will observe for signs of hypoglycemia.

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy is required when bilirubin levels exceed 14. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.

Correct Answer: 1,4,5 Rationale 1: Jaundice that occurs after 24 hours is physiologic. Rationale 2: Jaundice that appears within 24 hours is pathologic. Rationale 3: This might not be true, depending on a number of factors. Rationale 4: Phototherapy need is determined by the bilirubin level and age of the infant. Rationale 5: Kernicterus is the buildup of bilirubin in the gray matter cells of the brain. It causes irreversible neurological damage.

One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. The expected care for her neonate includes: 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.

Correct Answer: 2 Rationale 1: Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or chlamydia. Rationale 2: These are appropriate measures for an infant at risk for developing herpes simplex 2 infection. Rationale 3: These cultures are appropriate, but chest x-rays are not indicated. Chest x-rays are obtained if the neonate is thought to have group B strep pneumonia. Rationale 4: Parental rooming-in is encouraged, but penicillin does not treat viral illness.

The patient with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is: 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. "The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Correct Answer: 2 Rationale 1: Although this statement is true, the term "alloimmunization" is not likely to be understood by the patient. It is better to explain what is happening using more understandable terminology. Rationale 2: This explanation is accurate and easy for the patient to understand. Rationale 3: Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if mother is O and baby is A or B. Rationale 4: The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice.

The nurse assesses a 12-hour-old newborn's serum bilirubin level and finds it to be 14 mg/dl. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe. 2. Begin phototherapy. 3. Begin blood exchange transfusion. 4. Stop breastfeeding.

Correct Answer: 2 Rationale 1: Continued observation is only appropriate with normal findings. Rationale 2: Jaundice within 24 hours of birth is due either to Rh incompatibility or ABO incompatibility, and requires phototherapy. Rationale 3: Newborns with a bilirubin of 20 mg/dl or above might need an exchange transfusion. Rationale 4: The newborn should continue to breastfeed, even when undergoing phototherapy.

The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? 1. "If I had taken better care of myself, this wouldn't have happened." 2. "I've been sleeping very well since I had the baby." 3. "This is probably the doctor's fault." 4. "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

Correct Answer: 2 Rationale 1: Guilt is a common reaction of parents when they have an ill or congenitally abnormal child. Rationale 2: Most parents with an infant who is ill or who has a congenital abnormality find the situation very stressful and experience symptoms of anxiety, such as lack of appetite and insomnia. Rationale 3: Blame is a common reaction of parents when they have an ill or congenitally abnormal child. Rationale 4: Disbelief is a common reaction of parents when they have an ill or congenitally abnormal child.

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother: 1. Has a history of obsessive-compulsive disorder (OCD). 2. Has chlamydia. 3. Has delivered six other children by cesarean section. 4. Has a urinary tract infection (UTI).

Correct Answer: 2 Rationale 1: Obsessive-compulsive disorder (OCD) is not a risk factor for the infant. Rationale 2: Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and thus require close observation of the respiratory status and eyes. Rationale 3: Having multiple siblings, regardless of how they were delivered, is not a risk factor for the infant. Rationale 4: An infant whose mother has an untreated urinary tract infection might have been exposed to pathogens, but it is not known whether the mother in this question is on antibiotics.

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dl to 16.6 mg/dl in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe. 2. Begin phototherapy. 3. Begin blood exchange transfusion. 4. Stop breastfeeding.

Correct Answer: 2 Rationale 1: Physiologic jaundice is normal, but will need to be treated. Rationale 2: Physiologic jaundice is normal, but will need to be treated. Phototherapy might be required if the serum bilirubin level increases by more than 0.2 mg/dl per hour. Rationale 3: Newborns with a bilirubin of 20 mg/dl or above might need a blood exchange transfusion. Rationale 4: The newborn may continue to breastfeed.

What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old

Correct Answer: 2 Rationale 1: Respiratory distress developing at 12-24 hours of age might indicate sepsis. Rationale 2: Temperature instability is often seen with sepsis. Fever is rare in a newborn. Rationale 3: Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if the skin is cool and clammy. Rationale 4: Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life.

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place. 2. Axillary temperature 99.7°F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement

Correct Answer: 2 Rationale 1: The infant's eyes are covered to prevent possible injury to the retina; wearing no clothing except a diaper maximizes the amount of skin exposed to the light. Rationale 2: An infant with an increased temperature will have increased fluid loss, which can increase serum bilirubin levels through hemoconcentration. The temperature in this isolette should be lowered. Rationale 3: Breastfeeding should continue during phototterm-15herapy; removing the infant for feedings repositions the infant to prevent pressure areas. Rationale 4: This is an expected finding with phototherapy.

A patient in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. The nurse anticipates: 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborn's head is delivered.

Correct Answer: 2 Rationale 1: The newborn is not delivered on its side. Rationale 2: Direct tracheal suctioning by specially trained personnel is recommended for infants who experience absent or depressed respirations, heart rate slower than 80 beats/min, or poor muscle tone. Rationale 3: Positive pressure is not used to expand the lungs. Rationale 4: Intrapartum suctioning after the head is delivered is no longer recommended.

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate

Correct Answer: 2 Rationale 1: There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. Rationale 2: The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn. Rationale 3: The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. Rationale 4: The infant is not premature.

The nurse is caring for a 41-weeks'-gestation infant born yesterday. The newborn's hematocrit is 75%. The best action by the nurse based on this finding is to: 1. Inform the parents that their baby has an abnormal lab value. 2. Call the physician and report the hematocrit level. 3. Notify the blood bank that a transfusion will be required. 4. Increase breastfeeding frequency, and supplement between feedings.

Correct Answer: 2 Rationale 1: This answer is too vague. Parents need to know specifics, but described in lay terms. Rationale 2: Polycythemia is a hematocrit above 65% and has the potential for serious sequelae, including stroke and respiratory distress. This infant requires a partial exchange transfusion to treat the polycythemia. Rationale 3: This infant is not anemic but polycythemic. A partial exchange transfusion using crystalloids is the treatment. Rationale 4: Increasing fluid intake will not improve the polycythemia. A partial exchange transfusion using crystalloids is the treatment.

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note; Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalhematoma or excessive bruising 5. Cyanosis

Correct Answer: 2,3 Rationale 1: Pathologic jaundice occurs within the first 24 hours of life. Rationale 2: Physiologic or neonatal jaundice appears after 24 hours of life. Rationale 3: Jaundice is a yellowish coloration of the skin and sclera of the eyes that develops from the deposit of yellow pigment bilirubin in lipid- or fat-containing tissues. Rationale 4: These are risk factors for pathologic jaundice. Rationale 5: Jaundice is not associated with cyanosis.

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis, drainage, and corneal abrasions. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.

Correct Answer: 2,3,5 Rationale 1: Removing the baby from under the phototherapy lights and removing eye patches during feedings provide visual stimulation and facilitate attachment behaviors. Rationale 2: This prevents corneal abrasions. Rationale 3: This intervention prevents or facilitates prompt treatment of purulent conjunctivitis and abrasions due to irritation from eye patches. Rationale 4: The nurse should apply minimal coverage-diaper area only-to provide maximum exposure to phototherapy lights. Rationale 5: Repositioning allows equal exposure of all skin areas and prevents pressure areas.

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Deep-suction the airways. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.

Correct Answer: 3 Rationale 1: Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established. Rationale 2: This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid in the question. Rationale 3: When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure. Rationale 4: Blood pressure is insignificant during resuscitation efforts. This infant needs respirations established.

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). The nurse bases this assessment on all of the following data except: 1. Grunting respirations. 2. Nasal flaring. 3. Respiratory rate of 40 during sleep. 4. Chest retractions.

Correct Answer: 3 Rationale 1: Grunting with respirations is a characteristic of RDS. Rationale 2: Nasal flaring is a characteristic of RDS. Rationale 3: A respiratory rate of 40 during sleep is normal. Rationale 4: Significant chest retractions are characteristic of RDS.

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is: 1. "Your newborn likes to be touched." 2. "Stroking the newborn will help with stimulation." 3. "Visits must be scheduled between feedings." 4. "Your baby loves her pink blanket."

Correct Answer: 3 Rationale 1: Statements that encourage the parents to touch the newborn will help them bond with their child. Rationale 2: Statements that encourage the parents to stroke the newborn will help them bond with their child and provide stimulation. Rationale 3: The nurse always should encourage parents to visit and get to know their newborn, even in the NICU. Rationale 4: Comments that personalize the baby will tell the parents their baby is unique and special.

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? 1. Vasoconstriction and pallor 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer

Correct Answer: 3 Rationale 1: Vasoconstriction is the first physiologic response to a lowering temperature; it causes pallor. Rationale 2: This is an adequate blood sugar in a neonate. A level lower than 40 indicates hypoglycemic. Rationale 3: IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room-temperature IV fluids will increase the cold stress. Rationale 4: Radiant warmers are used to gradually increase the neonate's temperature.

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases. 3. Increased PCO2 4. Increased urination

Correct Answer: 4 Rationale 1: As fluid moves out of the lungs and into the bloodstream, alveoli open and kidney perfusion increases, thereby increasing urine output. Rationale 2: Pulmonary vascular resistance increases with hypoxia. Rationale 3: Increased PCO2 results from alveolar hypoventilation. Rationale 4: Increased urination could be an indication that the newborn's condition is improving.

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool guaiac testing 4. Assessment of hydration status

Correct Answer: 4 Rationale 1: Phototherapy does not affect head circumference. Rationale 2: Breastfeeding most likely can be continued. Rationale 3: The stools do not need to be tested for blood (guaiac testing). Rationale 4: Newborns being treated for jaundice experience a fluid volume deficit due to an increase in insensible water loss and frequent loose stools.

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? 1. "I'll bring you to your baby and then leave so you can have some privacy." 2. "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." 3. "I am so sorry this has all happened. I know how stressful this can be." 4. "Your baby is working hard to breathe and lying quite still, and has an IV."

Correct Answer: 4 Rationale 1: When bringing parents to see their ill newborn for the first time, it is important to prepare them for what they will see. Bringing parents without preparation is inappropriate. Rationale 2: Although this statement describes the treatment the baby is receiving, it is worded in medical jargon that will not be understood by most parents. Rationale 3: This response focuses on the nurse. Avoid saying "I know how you feel," because it is impossible for the nurse to actually know how patients feel. Rationale 4: This answer is best because it explains what the parents will see in terminology that they will understand.

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

Correct Answer: 4,5 Rationale 1: Rapid temperature elevation can cause hypotension and apnea. Rationale 2: The skin temperature should be monitored at least every 15-30 minutes to determine whether it is increasing. Rationale 3: IV fluids should be warmed prior to infusion. Rationale 4: The nurse should initiate efforts to block heat loss by evaporation, radiation, convection, and conduction. Rationale 5: The infant should be warmed slowly to prevent hypotension and apnea.