OB Practice: Nursing Care of the Newborn with Special Needs
The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?
20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.
The mother of a preterm infant tells her nurse that she would like to visit her newborn who is in the neonatal intensive care unit (NICU). Which response by the nurse would be the most appropriate?
"Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them. p 852
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs. pg 840
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?
"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.
A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?
0.15 mL The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL. p 848
A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?
0.5 to 1 mL/kg/h Minimal enteral feeding is used to prepare the preterm newborn's gut to overcome the many feeding difficulties associated with gastrointestinal immaturity. It involves the introduction of small amounts, usually 0.5 to 1 mL/kg/h, of enteral feeding to induce surges in gut hormones pg 842
What percentage of neonates require some type of assistance to transition to extrauterine life?
10% Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.
A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?
40 to 60 breaths per minute When performing newborn resuscitation, the nurse would ventilate at a rate of 40 to 60 breaths per minute.
A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?
Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.
A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?
Administer dextrose intravenously. The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg per dL, and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand. pg 840
A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.
Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Encourage skin-to-skin contact. Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?
Begin early feedings either by the breast or bottle. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia. pg 840
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants. pg 850
A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.
Increase the infant's hydration. Offer early feedings. Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.
The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?
Prepare for repeat hematocit levels q12h. Newborn infants of diabetic mothers (IDM) are at risk for polycythemia. A priority for the nurse is to observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results with hematocrit levels repeated every 12 hours. Blood glucose levels would be monitored more often than Q6H. Bleeding disorders do not correlate with the situation. CPAP may be needed but not as the priority. pg 836
A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?
Retinopathy of prematurity Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.
The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?
The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels. p.837
A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?
The neonate is small for its gestational age. Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology. pg 834
A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?
The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks of 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. p.858
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. 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. pg 835
A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?
The supply of brown adipose tissue is not developed. Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates.
A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?
With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance. p 858
What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?
ability to tolerate early oral feeding Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature, and an angular and pinched face are features common to both an SGA and a preterm baby.
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 A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.
During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?
asymmetrical movement A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. p 837
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?
conduction A conduction heat loss results from direct contact with an object that is cooler. p 850
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. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function. p 842
The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?
jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea. Jaundice is not part of the newborn hypoglycemic syndrome. Positive Moro reflex and palmar creases are normal. pg 840
A newborn is designated as extremely low birth weight. The nurse understands that this newborn's weight is:
less than 1,000 g. An extremely low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g. p. 834
A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?
paternal factors Fetal growth is dependent on genetic, placental, and maternal factors.
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 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).
The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?
polycythemia, probably due to chronic fetal hypoxia The small-for-gestational-age neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.
A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:
respiratory distress. Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time. p 846
Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?
tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia. pg 837
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood 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. p 837
The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?
Initiate early oral feedings. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority. pg 851
When preparing to resuscitate a preterm newborn, the nurse would perform which action first?
Place the newborn's head in a neutral position. 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 is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation. p 848
All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia?
an infant who had difficulty establishing respirations at birth Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?
dehydration The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held upright. Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue. pg 851
The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.
diabetes mellitus multiparity history of postdates gestation Maternal factors that increase the chance of bearing an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. pg 840
A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?
fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate. pg 842
A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?
respiratory distress syndrome 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.
Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?
respiratory rate of 60 to 70 bpm The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid.
A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:
term. A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is born between 34 and 37 weeks' gestation.
The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?
Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority. pg 850
An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?
RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute). p 842
The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress. pg 850
Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.
diabetes mellitus postdates gestation prepregnancy obesity Diabetes mellitus, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn's being large for gestational age.
A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.
encouraging kangaroo care during procedures removing tape gently from the skin using a colorful mobile for distraction Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective. p 855
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:
expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen). p 845
Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.
gestational hypertension maternal infection congenital heart disease Prenatal risk factors that can help identify the newborn that may need resuscitation include history of substance abuse, gestational hypertension, fetal distress due to hypoxia before birth, chronic maternal diseases, maternal or perinatal infection, placental problems, umbilical cord problems, difficult or traumatic birth, multiple births, congenital heart disease, maternal anesthesia or recent analgesia, or preterm or postterm birth.
What is a consequence of hypothermia in a newborn?
holds breath 25 seconds 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. p. 850
A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.
increased serum bilirubin levels clay-colored stools tea-colored urine Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.
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 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
The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?
meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails. pg 840
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 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. p. 858
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 a SGA infant?
placental factors 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, malformed and smaller placentas, with placental 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 admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?
undescended testes Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa. pg 841
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 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 pg 834
At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?
"Newborns who are appropriate for gestational age at birth have lower chance of complications than others." Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups. pg 834
The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?
Begin supervised feedings for the newborn. Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. Supervised breastfeeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcome, and hence aggressive screening and treatment is recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent hand washing while caring for them the gold standard. Breastfeeding will eventually establish some protective mechanisms. pg 843
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.
Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. Avoid coming to work when ill. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it. pg 852
A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?
fontanels When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels. Sunken fontanels suggest dehydration; bulging fontanels suggest overhydration
A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?
increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.
A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?
intubation and suctioning of the trachea Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. The nurse should not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea. p 837
A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?
meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia. pg 858
Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?
meconium stained fluids followed by tachypnea 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. pg 837
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?
newly born preterm infant Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern. pg 850
A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional sign should the nurse consider as an indication of respiratory distress syndrome (RDS) in the newborn?
sternal retraction The nurse should consider 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. pg 845
The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.
swaddling the newborn closely offering a pacifier prior to a procedure encouraging kangaroo care during procedures Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging kangaroo care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. pg 855
A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:
very low birth weight. A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight.
