OB EAQ Chapter 23

The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this?

"Are you cleaning with prepackaged commercial wipes?"

The student nurse asks the clinical instructor about changes in normal elimination patterns of infants. Which response given by the clinical instructor is most appropriate?

"Breastfed infants should pass stools three times a day for the first few weeks."

The nurse is counseling the parents of an infant who has physiologic jaundice after birth. At the time of discharge the mother asks, "What care should I take to prevent recurrence of jaundice in my baby?" How will the nurse respond to the mother's question?

"Breastfeed your baby 10 times a day."

The nurse is teaching a student nurse about stool patterns of a breastfed infant. What statement made by the student nurse indicates the need for further teaching?

"Stool would have a water ring in normal conditions."

The nurse is performing an evaluation and screening of a newborn. To estimate the blood glucose levels, the nurse collects blood from the infant by the heelstick method. What nursing intervention would be accurate while performing the heelstick method? Make a puncture no deeper than:

2.4 mm into the neonate's heel.

The nurse is caring for an infant who has undergone a circumcision. The infant weighs 3 kg. What is the maximum daily dose of oral liquid acetaminophen (Tylenol) that can be administered to the infant? Record your answer using a whole number.

225

The nurse is taking care of a newborn who is not yet circumcised. Which anesthetic agent does the nurse expect the primary health care provider to prescribe?

4% lidocaine (LMX4)

The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant?

9 hours after the infant is born

The nurse is assessing a newborn after 1 hour of delivery and finds that the newborn has chlamydia conjunctivitis. What prescription does the nurse expect from the primary health care provider?

A 14-day course of oral sulfonamide

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition?

A head circumference greater than chest circumference

On a winter morning the nurse finds the skin color of the newborn turning blue. The baby also has difficulty breathing. What should be the immediate nursing interventions to restore a normal condition in the baby?

Administer glucose to the newborn. Provide artificial ventilation to the newborn. Set the incubator at a temperature above 22° C.

A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety?

Administer ophthalmic solution.

The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse?

Administer vitamin K intramuscularly.

The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them?

Apply pressure on the forehead with a finger.

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects?

Assess blood pressure (BP) in all four extremities.

The nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools?

Bilirubin-induced gastric motility

The primary health care provider (PHP) prescribes ventilator support for a newborn. What finding would the PHP have assessed in the newborn?

Bluish discoloration of the skin

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?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

The nurse is educating a group of new mothers about the use of pacifiers for their infants. Which statement does the nurse include in the teaching? "Pacifiers should be:

Constructed as one piece with a shield."

The nurse observes a tissue injury in a newborn caused during birth. The nurse blanches the skin and finds no change in the affected area. What type of injury does the baby have?

Ecchymosis on the trunk

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? The neonate:

Exhibits normal findings.

After assessing an infant's health screening reports, the nurse instructs the mother to stop breastfeeding and switch to a soy-based formula. What findings most likely caused the nurse to recommend this change?

Increased galactose levels in the infant

The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant?

Intramuscular (IM) hepatitis B immune globulin (HBIG)

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?

Intravenous (I.V.) dextrose infusion

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored?

Kernicterus

Upon assessing the laboratory reports of an infant, the nurse finds an abnormality in the infant's bone development. The nurse instructs the parents to perform periodic checkups and monitor the growth of the infant. What did the nurse find in the infant's laboratory reports?

Low thyroxine (T 4) levels

The nurse is assessing a neonate who has undergone phototherapy. The nurse finds the transcutaneous bilirubinometry (TcB) reading to be 13 mg/dL. What should the nurse infer about the neonate from these findings? The neonate:

May require blood transfusion.

The nurse is caring for an infant with candidiasis. Despite being treated with topical clotrimazole (Pedesil), the infection persists. Which medication does the primary health care provider prescribe?

Oral nystatin (Mycostatin)

The nurse is caring for an infant who cries in a high-pitched voice. When the crying ceases, the nurse wants to check the blood pressure (BP) of the newborn. What device does the nurse most preferably use?

Oscillometric monitor

The nurse is assessing a preterm baby and observes dark red skin color with harlequin signs on the skin. What does the nurse infer from these findings? The baby has:

Polycythemia.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures:

Prevent exposure to people with upper respiratory tract infections. Keep the infant away from secondhand smoke. Avoid loose bedding, waterbeds, and beanbag chairs. Keep a bulb suction available at home.

The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe? "It is used in the baby to:

Prevent suffocation and clear airway obstruction."

The nurse reports a neonate's heart rate as 9 beats in 6 seconds. What does the nurse expect the primary health care provider (PHP) to advise in order to restore the normal heart rate?

Provide ventilation support.

The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate?

Provide warmth to the neonate.

The nurse is collecting a neonate's blood sample by the heelstick method. What safety measure will the nurse follow to prevent necrotizing osteochondritis in the neonate?

Puncture the skin up to 2.4 mm.

The nurse is caring for a 3-week-old infant. Upon assessment, the nurse finds that the infant has impaired acoustic nerve functioning. What does the nurse infer from this finding about the infant's clinical condition? The infant has:

Reduced hearing abilities.

The nurse is assessing a newborn undergoing phototherapy. What changes would the nurse likely notice in the newborn during the process? Increased:

Stool frequency

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?

The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg.

The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report?

The ability to suck

Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this?

The infant requires 40% oxygen support.

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature?

The mother has been administered magnesium sulfate.

Which statement provides helpful and accurate nursing advice concerning bathing the newborn?

Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Powders are not recommended because the infant can inhale powder.

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition?

Urinary output

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?

Using the vastus lateralis muscle By inserting the needle at a 90-degree angle

The nurse is assessing a neonate who is administered vitamin K intramuscularly (IM). What changes in the neonate would the nurse primarily monitor to ensure safety?

Yellow discoloration of sclera

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae:

are benign if they disappear within 48 hours of birth.

The nurse administers concentrated oral sucrose through the suckling method to a neonate before performing the heelstick method. Why would the nurse do this?

comfort the infant

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to:

expect a yellowish exudate to cover the glans after the first 24 hours.

With regard to umbilical cord care, nurses should be aware that:

the stump can easily become infected.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

use a rear-facing car seat.

When weighing a newborn, the nurse should:

weigh the newborn at the same time each day for accuracy.