OB/Peds Final exam
An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?
tachypnea
The nurse is caring for a 12-year-old child with Crohn disease. A primary assessment the nurse would want to make when caring for the child would be to note if:
the child has a temperature.
Which is the best place to perform a heel stick on a newborn?
the fat pads on the lateral aspects of the foot
The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
A newborn's caregivers ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?
"Always wash your hands before you pick up or provide care to your newborn."
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
2-day-old baby who is breathing irregularly at 70 breaths per minute.
A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?
Less than 1,000 g.
What action shows an example of Erik Erikson's developmental task for the infant?
The infant cries and the caregiver picks the child up.
The nurse is doing a presentation for a group of nursing students about the topic of menstrual disorders. After discussing the disorder secondary amenorrhea, the students make the following statements. Which statement made by the nursing students is the most accurate regarding the cause of secondary amenorrhea?
"Emotional stress can be a cause of this disorder."
The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Which is the nurse ' best response?
"Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." Ppt says "4 times more common in males and follows a familial pattern"
The nurse has performed client teaching to a 15-year-old boy with Crohn disease, and his parents, regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning occurred?
"I have to be careful because I am prone to not absorbing nutrients."
The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby?
"It's a good idea to stop drinking alcohol 3 months before trying to get pregnant."
A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching?
"My daughter can eat any kind of fruit."
A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate?
"Neonates born by cesarean do not benefit from the squeezing of the contractions which help to clear the lungs."
The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Which is the nurse ' s most appropriate response?
"Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?
"Place the newborn on the back to sleep and stomach to play."
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?
"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply.
"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats."
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask?
"Tell me about the types of stools you child has been having."
The caregiver of a 1-year-old boy calls the nurse, upset that his wife has just told him that their son is being given a hormone. His wife says that the pediatrician called it human chorionic gonadotropic hormone but that is all she understood. The nurse most accurately clarifies the caregiver's question by making which statement regarding the son's treatment?
"The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place."
The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is the nurse ' s most appropriate response?
"The enema will help confi rm the diagnosis and has a good chance of fi xing the intussusception."
The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child ' s lip and palate will most likely be repaired. Which is the nurse ' s best response?
"The lip is repaired in the fi rst few weeks of life, but the palate is not usually repaired until the child is 18 months old."
A first time breastfeeding mother phones the clinic nurse because she is concerned about her 3-month-old's stools. Which statement indicates a possible problem?
"The stools are foamy and smell terrible."
The novice nurse is discussing the diagnosis of intussusception with a group of peers. What statement demonstrates the nurse's appropriate understanding regarding this disorder?
"The stools of the infant are called currant jelly stools and consist of blood and mucus."
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement, by the caregiver best indicates the nurse's teaching was effective?
"We will fold down the front of her diaper under the umbilical cord until it falls off."
The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Which is the nurse ' s best response?
"Your infant will need to have some tests in the emergency department to determine whether anything serious is going on. S&S of intussusception
The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?
0.5 mL
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?
108 bpm The heart rate of a fetus in utero averages between 110 and 160 beats/minute.
Which client most likely has ulcerative colitis rather than Crohn disease?
16-year-old female with continuous distribution of disease in the colon, distal to proximal Explanation: Ulcerative colitis is usually continuous through the colon while the distribution of Crohn disease is segmental. Crohn disease affects the full thickness of the intestine while ulcerative colitis is more superficial. Both conditions share age at onset of 10 to 20 years, with abdominal pain and fever in 40% to 50% of cases.
How long is the neonatal period for a newborn?
28 days
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids?
6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:
7-10
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. Explanation: Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).
The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition?
A sausage-shaped mass in the upper midabdomen
The nurse is caring for a pediatric client who is scheduled for the surgical removal of a Wilms tumor. Which is contraindicated in the client's care?
Abdominal palpation
Which findings by a nurse would be considered abnormal when examining the eyes of a newborn? Select all that apply.
Absent red reflex Blue-tinged sclera Explanation: The normal response is a red reflection from the retina, and absence of a red reflex is associated with congenital cataracts. The sclera should be white, not blue. All other findings are normal variants for an eye exam.
The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the preoperative period?
Administer intravenous fl uids and antibiotics.
Which clinical manifestation is seen in the child with hydrocephalus?
An extremely large and rapidly growing head
A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confi rm the diagnosis of dehydration?
Analysis of serum electrolytes.
A newborn is returned to the newborn observational nursery demonstrating signs of cold stress after a prolonged bath. Which action would be a priority for the nurse?
Assess blood sugar level. Explanation: For a hypothermia client, a nurse would observe for clinical signs of cold stress, such as hypoglycemia.
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition?
Barium enema
A nurse teaches new parents that the best way to help prevent infections in the newborn is which method?
Breastfed A major source of IgA, which helps in immunity, is human breast milk.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum
After assessing a normal newborn, the nurse knows that oxygen administration is needed immediately. Which of the following findings would support the nurse's decision?
Central cyanosis
A nurse is preparing to perform an initial newborn assessment, which parameters should be most important to assess in the first minute of life?
Color, respirations, heart rate
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test?
Compare the identification bracelets prior to leaving the newborn with the mother.
The nurse is caring for a 9-month-old with diarrhea secondary to rotavirus. The child has not vomited and is mildly dehydrated. Which is likely to be included in the discharge teaching?
Continue breastfeeding per routine. Breastfeeding is usually well tolerated.
The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?
Cover the glans generously with petroleum jelly.
The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?
Creases on two-thirds of the foot
A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight is significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis?
Crohn disease Explanation: Intermittent abdominal pain, anorexia, diarrhea, growth delays, and perianal lesions are characteristic of Crohn disease
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?
Dry the newborn and place it skin-to-skin on mother.
A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage bladder spasms?
Encourage high fluid intake.
What is a true statement regarding the developmental milestones of the 30-month-old child?
Full set of primary teeth
The nurse is teaching a mother of a 1-year old girl about weaning her from the bottle and breast. Which recommendation should be part of the nurse's plan?
Give the child an iron-fortified cereal. Explanation: The nurse would be sure to tell the mother to feed her child iron-fortified cereal and other iron-rich foods when she weans her child off the breast or formula.
The nurse evaluates the laboratory test results of a newborn that is 4 hours old. Which of the following results should require further investigation?
Glucose 34 mg/dl Glucose <40mg/dl is considered hypoglycemic.
The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis?
Hard, moveable "olive-like mass" in the upper right quadrant
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
Hyperbilirubinemia
The nurse is caring for a child diagnosed with hydronephrosis. Which manifestation is consistent with complications of the disorder?
Hypertension
While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin?
IgA
A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, finds the pain relieved, and calls the nurse. Which should be the nurse
Immediately notify the health-care provider of the child ' s status. The sudden relief of pain could be due to a rupture of the appendix.
The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse ' s next action?
Immediately obtain all vital signs with a quick head-to-toe assessment. Ominous manifestations: •Bloody diarrhea •fever •severe lethargy
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?
Instill 0.5% ophthalmic erythromycin.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case?
Intussusception Explanation: Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this?
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.
A nurse is collecting data for a baby with suspected neonatal hypoglycemia. Which set of findings supports the diagnosis?
Jitteriness, high-pitched cry, lethargy
The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which would the nurse expect to find in the plan of care?
Keep infant NPO; begin intravenous fl uids at maintenance; place nasogastric tube (NGT) to low wall suction.
A nurse is performing assessments on several newborns. Which of the following developmental features should the nurse expect to be absent in a 41-week newborn
Lanugo Post term babies usually have less or no lanugo.
To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do?
Maintain the infant's temperature above 97.7°F/36.5°C.
Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?
Mongolian spot
A new mother is very concerned that her newborn son has not yet voided since his birth 8 hours ago. What is the nurse's best response?
Most newborns urinate within 24 hours of birth, we will continue to watch him
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition?
Mother age 42 with pregnancy
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her infant needs the injection. The nurse best response by the nurse should be
Newborn infants are deficient in vitamin K, and this injection prevents abnormal bleeding
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?
Obtain a transcutaneous bilirubin level.
A nurse is caring for a neonate with a suspected cardiac disorder. During the assessment the nurse palpates decreased femoral pulses. The next priority action should be to:
Obtain blood pressure of upper and lower extremities to evaluate for coarctation of the aorta
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?
Only occurs with feeding
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is:
Painless rectal bleeding
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus.
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.
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Remove wet blankets.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician. Explanation: Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanelles are not palpable. What action would the nurse take?
Report the findings to the pediatric provider. Explanation: These findings are consistent with craniosynostosis, or premature fusion of the cranial sutures.
The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse takes action to prevent which complication first?
Respiratory distress
A nurse is carefully monitoring the oxygen saturation of a newborn who has respiratory distress syndrome. The nurse is aware that a complication of oxygen toxicity is:
Retinal bleeding
The nursing instructor is conducting a training session on the basic care for a newborn male. The instructor determines the session is successful after the students correctly choose which action to avoid?
Retracting the foreskin over the glans to assess for secretions
Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?
Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.
At what age would it be okay to introduce carrots to an infant's diet?
Solid food can be introduced at 4 to 6 months of age.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
The mother squeezes soapy water from the wash cloth over the glans.
A nurse assessing a client in labor notes thick, green-stained amniotic fluid. Which intervention should be priority immediately following the birth of the newborns head?
Suction the infant
A woman has just given birth vaginally to a newborn. Which action will the nurse do first?
Suction the mouth and nose.
The nurse is caring for a 6-month-old infant who was admitted to the emergency room 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention?
Take a stool culture
The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical manifestation would likely have been noted in the child with this diagnosis?
Tea-colored urine
The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history?
The child recently had an ear infection.
A newborn is diagnosed with hypospadias and the parents want the newborn to be circumcised. What would be the best response by the nurse?
The foreskin is needed for repair.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?
The infant is experiencing moderate difficulty in adjusting to extrauterine life. Explanation: The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.
After birth when inspecting her newborn baby girl, the mother notices a discharge from the nipples of both breasts of the baby. The nurse should explain that this evidence of:
The influence of the mothers hormones
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.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch.
The nurse is assessing speech development in the 2-year-old whose family uses both Spanish and English in the home. What finding is of concern?
The toddler speaks 15 words between the two languages. Explanation: Of concern is speaking only 15 words between Spanish and English. At 20 months, the bilingual child should use 20 words. The other findings fit the norms for a bilingual child.
The nurse is examining a newborn and notes that there is swelling on the newborn's head, limited to the right side of the head. How should the nurse interpret this finding?
This is a cephalohematoma and will spontaneously resolve without interventions. The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. This is not a caput since there is blood accumulation under the periosteum and not tissue swelling.
A postpartum client approaches the nurse with concerns that her newborn has small whitish, pinpoint spots over the nose. 'My beautiful baby looks like he has acne'. The best response by the nurse at this time should be
This is called milia and it is caused by retained sebaceous secretions
In caring for a child with nephrotic syndrome, which intervention will be included in the child's plan of care?
Weighing on the same scale each day Explanation: The child with nephrotic syndrome is weighed every day using the same scale to accurately monitor the child's fluid gain and loss. The child with nephrotic syndrome is very edematous so increasing fluid intake would be counterproductive to care needed. In nephrotic syndrome the urine is tested for protein, not glucose. Ambulation is important for all but it is not specific to the child with nephrotic syndrome.
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
The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment finding?
absent Moro reflex Explanation: An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex. An absent grasp reflex and hand weakness is noted with a lower brachial plexus injury. Facial asymmetry is associated with a cranial nerve injury.
The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100℉ (37.8℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have:
acute glomerulonephritis. Explanation: Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103℉ to 104℉ (39.4℃ to 40℃) at the onset, but decreases in a few days to about 100℉ (37.8℃). Slight headache and malaise are usual, and vomiting may occur.
A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?
apnea Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis.
A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother; baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night; baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother; baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first?
baby C Explanation: Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of 4 to 6 mg/dL and greater), can lead to jaundice, a yellow staining of the skin. Only baby C has hyperbilirubinemia. All the vital signs are within normal limits: Heart rate 110 to 160 beats per minute; respiratory rate 30 to 60 breaths per minute; axillary temperature 97.7°F to 98.6°F (36.5°C to 37°C); and blood pressure 60-80/40-45 mm Hg.
The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet?
bananas
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?
bright red, raised bumpy area noted above the right eye A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision.
A primiparous mother gave birth to an 8 lb 12 oz (4 kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice?
cephalohematoma Explanation: Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender and being breastfed. Blood type incompatabliity is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.
A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatologist?
cryptorchidism undescended testicles
Which finding is indicative of hypothermia of the preterm infant?
nasal flaring Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting).
A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?
face
A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?
higher oxygen content of the circulating blood
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
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?
lack of subcutaneous fat
While caring for a neonate of a diabetic mother, the nurse should monitor the neonate for which complication?
macrosomia
The nurse is caring for a newborn with esophageal atresia. When reviewing the mother ' s history, which would the nurse expect to fi nd?
maternal polyhydramnios
Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?
meconium stained fluids followed by tachypnea
The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible urinary tract infection is:
obtaining a clean catch voided urine.
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
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?
prepare the infant for surgery
It would be best to place an infant with a myelomeningocele in which position prior to surgery?
prone
A child diagnosed with acute glomerulonephritis will most likely have a history of:
recent illness such as strep throat.
The nurse pulls the 5-month-old to sitting position from supine and notes head lag. The nurse's response is to:
refer the infant for developmental and/or neurologic evaluation. Explanation: There should be no head lag by 4 months. Head lag in the 5-month-old may indicate motor or neurologic problems and needs immediate follow-up
All the options are signs of respiratory distress in the newborn except:
respiratory rate >50 breaths/minute. Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.
The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?
retinopathy
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:
severe dehydration. greater than 10% of body weight
The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period.
supine
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.
yellowish gold color stringy to pasty consistency
A nurse is caring for a premature neonate who has gastroesophageal reflux. The goal of treatment for this neonate is to:
· Achieve normal gastric emptying
