OB exam CH 23

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels (fontanelles) Explanation: When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels (fontanelles). Sunken fontanels (fontanelles) suggest dehydration; bulging fontanels (fontanelles) suggest overhydration.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body Explanation: A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large-for-gestational-age (LGA) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

The nurse determines a newborn is small-for-gestational-age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores Explanation: The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 ml whole blood is considered hypoglycemia.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position. Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive pressure ventilation would be used before endotracheal tube (ETT) insertion. ETT insertion is used if the newborn remains apneic or positive pressure ventilation is ineffective. Epinephrine is given after chest compressions are initiated.

When caring for a 1-week-old infant with jaundice, the nurse observes the infant's urine to be dark in color. The nurse would also expect to assess which as indicative of significant hyperbilirubinemia? Select all that apply.

Poor feeding and lethargy Late passage of meconium stool Light, tan-colored stool after milk intake Explanation: Poor feeding and lethargy, late passage of meconium stool, and light, tan-colored stool after milk intake are features of significant hyperbilirubinemia. Decrease in volume of urination is not seen with hyperbilirubinemia. Jaundice limited to the nose, eyes, and ears is physiologic jaundice and does not indicate significant hyperbilirubinemia.

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

Sternal retraction The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?

The infant was a preterm, low-birth-weight and small-for-gestational-age Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Explanation: Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile Explanation: A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis Explanation: The respiratory system is the last system to mature. Therefore, the preterm newborn is at great risk for respiratory complications, one of which is atelectasis.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

clustering care and activities Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant?

hypoglycemia Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

During an extended initial resuscitation, what additional complications may be experienced by the infant during the resuscitation? Select all that apply.

hypoglycemia dehydration Explanation: The stress may cause accelerated metabolism of glucose stores and hypoglycemia. Dehydration may occur due to insensible water loss during ventilation and other resuscitative procedures. Hypokalemia, anemia, and leukocytosis are not complications during an initial resuscitation.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing Explanation: The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea Explanation: Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.

Which finding is indicative of hypothermia of the preterm neonate?

nasal flaring Explanation: Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant?

placental factors Explanation: Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption (abruptio placentae), malformed and smaller placentas, with placenta previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia Explanation: Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm Explanation: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,:

the ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

the pressure the nurse uses when the hand squeezes against the bag Explanation: The pressure exerted by the nurse's hand squeezing the bag controls the pressure delivered by an anesthesia bag. An ambu or resusci bag has a blow-off value that limits the pressure administered.