PassPoint The Neonate

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan? Term neonates generally have few creases on the soles of their feet. Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal. If erythema toxicum is present, it will be treated with antibiotic therapy. Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Milia are white papules resulting from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Parents should be instructed to avoid scratching them to prevent secondary infection. Term neonates generally have many creases on the soles of their feet. Preterm neonates may have only a few creases due to their immaturity. Strawberry hemangiomas are elevated areas formed by immature capillaries that will disappear over time. Port wine stains are deep, dark red discolorations that require laser therapy for removal. Erythema toxicum is a newborn rash or "flea bite" rash that requires no treatment and disappears over time.

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation? unequal gluteal folds unlimited adduction of the affected leg lengthening of the limb on the affected side crepitus of the affected hip on movement

unequal gluteal folds Unequal gluteal folds are a sign of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip is not felt, but an audible click may be heard when the hip on the affected side is adducted.

A home care nurse assesses a 4-day-old infant. The infant has developed a yellowish tinge to the face extending to the mid-chest. Which of the following is the priority nursing intervention? Assess the jaundice using a transcutaneous monitor. Advise the mother to stop breastfeeding and offer formula instead. Notify the baby's physician as soon as possible. Monitor the jaundice over the next 24 hours.

Assess the jaundice using a transcutaneous monitor. Jaundice that appears after 24 hours of age is considered to be physiologic and needs to be further assessed. Nurses are able to assess a preliminary level of jaundice by using a transcutaneous monitor to determine the level of bilirubin, instead of simply observing the skin color, which is not an accurate measure of bilirubin. The physician does not need to be notified unless the serum bilirubin levels are high. This is not likely breastfeeding jaundice so breastfeeding can continue.

The nurse reviews the daily weights of a breastfeeding term newborn. What conclusion does the nurse make about the weight loss? The health care provider needs to be notified. The newborn needs to be reweighed. Breastfeeding is going as expected. Supplementation is now needed.

Breastfeeding is going as expected. Up to a 10% weight loss in the first few days of life is normal in a breastfeeding newborn. This newborn's weight loss is under 10%, so the nurse can assume that breastfeeding is going as expected. There is no need to reweigh the newborn or notify the health care provider. Best breastfeeding practices do not include supplementation unless there is a medical reason.

While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which action should the nurse take next? Call the physician to report the problem. Do nothing because this is normal. Check the baby's urine for hematuria. Encourage the mother to feed the baby to decrease dehydration.

Do nothing because this is normal. Female neonates may have some vaginal bleeding in the first or second day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician needn't be called. This bleeding is normal and doesn't indicate dehydration or hematuria.

Which of the following structures should be closed by the time the child is 2 months old?

The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.

The nurse is caring for a neonate diagnosed with early onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents' teaching plan? Wash hands thoroughly before touching the neonate. Visit but do not touch the neonate. Wear protective gear near the isolation incubator. Wear a mask when holding the neonate.

Wash hands thoroughly before touching the neonate. The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. It is not necessary for parents to wear protective gear near the isolation incubator. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. The baby will not spread sepsis via respiratory droplets to parents, so it is not necessary for the parents to wear a mask.

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents? a neonate who's in good condition a neonate who needs additional oxygen to improve the Apgar score a neonate who's mildly depressed a neonate who's moderately depressed

a neonate who's in good condition An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? first period of reactivity respiratory distress a state of deep sleep drug withdrawal

a state of deep sleep At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal.

A nurse has been teaching a new mother how to feed her infant who was born with a cleft lip and palate. Which action by the mother indicates that the teaching has been successful? providing fluids with a small spoon placing the nipple in the cleft palate burping the baby frequently placing the baby flat during feedings

burping the baby frequently Because an infant with a cleft lip and palate can not grasp a nipple securely, the infant may swallow a large amount of air during feedings and, therefore, require frequent burping. An infant with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons shouldn't be used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug? naloxone betamethasone naltrexone promethazine

naloxone The drug of choice to reverse opioid-induced respiratory depression in a neonate is naloxone, which reverses the effects of opioids. Betamethasone is administered to enhance surfactant production in preterm neonates.Naltrexone is used to relieve pruritus from epidural narcotics.Promethazine is used to control nausea and vomiting in the mother.

When assessing a postterm neonate, what is considered a normal finding? wrinkled, peeling skin red abdominal rash small hands and feet flattened nose

wrinkled, peeling skin A common finding for postmature neonates is wrinkled, peeling skin.Flattened nose is associated with neonates who have trisomy 21, not with a postmature neonate.Small hands and feet are typically found in preterm and small-for-gestational-age neonates, not in a postterm neonate.There is no relationship between postmaturity and a red abdominal rash. An abdominal rash may be seen in any newborn in the first few days of life.

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess? shoulder dystocia small birth weight immature lung function hypoglycemia

shoulder dystocia This neonate exhibits findings of a post-term infant. Typically they are larger in size and more at risk for having shoulder dystocia. Immature lung function, hypoglycemia, and small birth weight are more common in pre-term infants.

A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel.

fontanel is a diamond-shaped membranous interval located at the intersection of the coronal, sagittal, and metopic sutures. It typically closes by age 18 months.

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement? "Like most women, I have immunity against the Rh factor." "Antibodies are not usually formed until after exposure to an antigen." "My blood couldn't neutralize antibodies formed from my first pregnancy." "My other baby had a different father."

"Antibodies are not usually formed until after exposure to an antigen." The problem of Rh sensitivity arises when the mother's blood develops antibodies after fetal red blood cells enter the maternal circulation. In cases of Rh sensitivity, this usually does not occur until after the first pregnancy. Hence, hemolytic disease of the newborn is rare in a primiparous client. A mismatched blood transfusion in the past or an unrecognized spontaneous abortion could also result in hemolytic disease because the transfusion or abortion would have the same effects on the client. The statement about the other baby having a different father may be true. However, if both fathers were Rh-positive, then sensitization could occur. Most women do not have immunity against the antibodies formed when Rh-positive cells enter the mother's bloodstream. Antibodies are not neutralized by the mother's system.

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction? "The molding was caused by an overlapping of the baby's cranial bones during my labor." "The molding will usually disappear in a couple of days." "Brain damage may occur if the molding does not resolve quickly." "The amount of molding is related to the amount and length of pressure on the head."

"Brain damage may occur if the molding does not resolve quickly." Caput succedaneum is common after the use of a vacuum extractor to assist the client's expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding.

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place? "Infants should ride in a rear-facing car seat until they weigh 30 lb (13.6 kg) or are 2 years old." "Infants should ride in a rear-facing car seat until they weigh 25 lb (11.3 kg) or are 1 year old." "Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old." "Infants should ride in a rear-facing car seat until they weigh 20 lb (9.1 kg) or are 1 year old."

"Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old." The American Academy of Pediatrics recommends that infants should ride in a rear-facing car seat until they have reached the maximum weight or height allowed by the car seat manufacturer or until they are at least 2 years old.

The nurse is providing teaching to the mother of a newborn with early jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the mother makes which response? "My baby should not get hyperbilirubinemia if I place him near a window in the sun light." "Since I'm exclusively breastfeeding, the risk of my baby having hyperbilirubinemia is very low." "My baby will be 3 days old at discharge, and I will not need to worry about hyperbilirubinemia." "Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects."

"Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects." Kernicterus is a consequence of elevated bilirubin levels that can have lifelong central nervous effects. This is a true statement. Infants that have elevated bilirubin levels need close monitoring until the bilirubin levels fall. Placing the infant in the sun light may cause thermoregulation issues such as overheating. Infants will burn very easily in the sun. Bilirubin level peak at 72 to 120 hours of age. If a baby is discharged at 3 days, the baby may need follow-up until the peak has been determined and the levels fall. Exclusive breastfeeding is a risk factor for an infant developing severe hyperbilirubinemia.

On the first postpartum day, a neonate diagnosed with an ABO incompatibility has a bilirubin level of 10 mg/dL (170 µmol/L). After teaching the parents about this condition, which statement by the parents about the neonate indicates the need for additional teaching? "The baby will need an exchange transfusion with type A blood." "Phototherapy causes the baby's stools to be bright green." "The baby may become anemic over the next 2 weeks." "Breastfeeding may need to be stopped temporarily."

"The baby will need an exchange transfusion with type A blood." ABO incompatibility occurs when the mother has type O blood, and the neonate is A, B, or AB. This condition is not as serious as Rh incompatibility. The mother needs further instructions when she says the neonate will require an exchange transfusion with type A blood. Unless the bilirubin concentration reaches the dangerous level (~20 mg/dL or 342 umol/L), an exchange transfusion is not usually performed. If an exchange transfusion does become necessary, type O blood is used.Phototherapy is the common treatment for ABO incompatibility.The neonate may have bright green stools as bilirubin is broken down and excreted in the stool. The mother may need to temporarily halt breastfeeding, but she may pump the breasts and continue feeding after the first 48 hours.The destruction of the neonate's red blood cells occurs after birth, so the neonate may become anemic until the hemolysis ceases, usually within 2 weeks.

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My mother started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client? "Give the infant iron-fortified rice cereal at 1 year of age." "A small amount of rice cereal given once in a while is okay." "Wait until the infant is at least 4 months of age before using cereal." "Give cereal in a bottle mixed well with the formula."

"Wait until the infant is at least 4 months of age before using cereal." Breast milk or formula should provide adequate nourishment for a neonate until 4 to 6 months of age.Cereal, regardless of the amount, given before the age of 4 months is not easily digested by the neonate and may lead to food allergies and possibly aspiration.Cereal should not be given in a bottle. Doing so could lead to obesity or aspiration.The infant's iron stores need to be fortified with formula with iron or cereal with iron at 4 to 6 months of age.

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching? "Iron-fortified formulas are usually recommended for newborns." "Bottle-fed babies up to 6 months of age may gain as much as 1 ounce (30 g)/day." "Bottle-fed babies will usually regain their birth weight by 10 to 14 days of age." "Whole milk is an acceptable alternative to formula once the baby is 4 months old."

"Whole milk is an acceptable alternative to formula once the baby is 4 months old." Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 oz (30 g)/day up to age 6 months.Iron-fortified formulas are recommended.Bottle-fed neonates may regain their birth weight by 10 to 14 days of age.

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which response by the nurse would be most appropriate? "You and the baby are both Rh-negative." "You are Rh-positive, and the baby is Rh-negative." "The baby and you are both Rh-positive." "You are Rh-negative and the baby is Rh-positive."

"You are Rh-negative and the baby is Rh-positive." Hemolytic disease of the newborn is associated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative the infant is Rh-positive. About 13% of Caucasians, 7% to 8% of people of African descent, and 1% of people of Asian descent are Rh-negative. Rh-positive cells enter the mother's Rh-negative bloodstream, and antibodies to the Rh-positive cells are produced. In a subsequent pregnancy, the antibodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia.

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond? "All babies born to HIV-positive women are infected with HIV, but your baby won't have symptoms for years." "Your child may have acquired HIV in utero, but we won't know for sure until the child is older." "Chances are the baby will be okay because you don't have AIDS yet." "Don't worry. It's too soon to tell."

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older." The nurse should explain to the mother that the neonate might have acquired HIV in utero, but that a diagnosis can't be made until the neonate is older. Diagnosing AIDS in neonates is difficult because all neonates of women with HIV receive maternal antibodies and therefore initially test positive for HIV antibodies. Saying, "Don't worry. It's too soon to tell" minimizes the mother's concern and doesn't provide specific information. Saying that chances are the neonate will be okay could promote false hope. Stating that all neonates born to HIV-positive women are infected isn't true. Neonates of HIV-positive mothers have a 25% to 30% chance of developing HIV.

A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: 12 to 18 months. 2 to 3 months. 9 to 10 months. 6 to 8 months.

12 to 18 months. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.

A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? The cast will be removed when the baby begins to crawl. A new cast is needed every 1 to 2 weeks. The cast will be removed in 6 weeks. A short leg cast is applied when the baby is ready to walk.

A new cast is needed every 1 to 2 weeks. Because a neonate grows so quickly, the cast may need to be changed as often as every 1 to 2 weeks. A cast for congenital clubfoot isn't left on for 6 weeks because of the rapid rate of the infant's growth. By the time an infant is crawling or ready to walk, the final cast has long since been removed. After the cast is permanently removed, the baby may wear a Denis Browne splint until the child is 1 year old.

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which characteristic does the nurse recognize as most common in neonates whose mothers smoked during pregnancy? 42-week, 1-day-old infant who weighs 7 lb, 2 oz (3,239 g) 39-week, 4-day-old infant who weighs 5 lb, 5 oz (2,415 g) 39-week, 1-day-old infant who weighs 9 lb, 10 oz (4,375 g) 40-week infant who weighs 7 lb 4 oz (3.295 g)

39-week, 4-day-old infant who weighs 5 lb, 5 oz (2,415 g) Neonates of women who smoked during pregnancy are small for gestational age for two reasons: Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus; and smokers are at greater risk for poor nutrition. These neonates are more likely to be preterm than postterm because smoking causes maternal vasoconstriction, decreases placental perfusion, and induces uterine contractions. A small for gestational age infant generally weighs less than 5.5 lb (2,500 g). Large size for gestational age results from increased nutrient transfer to the fetus, such as in a neonate who receives excessive glucose from a mother with diabetes mellitus. A large for gestational infant is generally more than 9 lb (4,091 g). The infant who is appropriate for gestational age can range from 5.5 lb to 9 lb (2,500-4,091 g) with the average around 6.5-7.5 lb (2,955-3,409 g). A postterm newborn is an infant born from a pregnancy lasting longer than 42 weeks.

The nurse is caring for a neonate who has a suspected neonatal sepsis. The healthcare provider's order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record your answer using a whole number.

85 First, convert the weight to kilograms (in the United States):7 lb, 8 oz = 7.5 lb7.5 lb ÷ 2.2 lb/kg = 3.4 kgThen, multiply the kilograms of body weight by 100 mg (dose given):3.4 kg X 100 mg/kg/day = 340 mg/day.Next, divide the total daily dose by the number of doses per day:340 mg/day ÷ 4 dose/day = 85 mg/dose.

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonate responds to gentle stimulation by withdrawing. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? Assign an Apgar score of 10, place in the neonate in modified Trendelenburg position, and suction the neonate's nose. Assign an Apgar score of 6, place the neonate in modified Trendelenburg position, and initiate a code to gain assistance from the code team. Assign an Apgar score of 7, place the neonate in modified Trendelenburg position, and begin artificial respirations. Assign an Apgar score of 9, place the neonate in modified Trendelenburg positi

Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx. The neonate should be assigned an Apgar score of 9 because the neonate is pink (2 points for color) , withdraws in response to stimulation (2 points for reflex irritability), is moving all extremities (2 points for muscle tone), has a heart rate of 110 beats/minute (2 points for heart rate), and has an irregular respiratory effort (1 point for respiratory effort). The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

A nurse is about to give a full-term neonate their first bath. How should the nurse proceed? Bathe the neonate only after vital signs have stabilized. Scrub the neonate's skin to remove the vernix caseosa. Clean the neonate with medicated soap. Wash the neonate from feet to head.

Bathe the neonate only after vital signs have stabilized. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions through which microorganisms can enter. The nurse should wash the neonate from head to feet.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next? Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. Obtain the neonate's footprints and compare them with the footprints obtained at birth. Replace the identification bands. Reprimand the parents for allowing the identification bands to come off.

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? Contact the health care provider (HCP). Continue feeding every 3 to 4 hours since the weight loss is normal. Switch to a soy-based formula because the current one seems inadequate. Change to a higher-calorie formula to prevent further weight loss.

Continue feeding every 3 to 4 hours since the weight loss is normal. This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the neonate's intake varies from one feeding to another. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the HCP should be called.

On the second postpartum day, the nurse enters the room and notices that the client is holding her crying baby and lightly rubbing the infant's back. The client states, "I don't know why she won't stop crying all the time." Which of the following is the most appropriate nursing intervention? Tell the client that her baby is hungry and that she needs to breastfeed. Demonstrate ways that the client can comfort her baby. Refer the client to a social worker to discuss her coping skills. Ask the client if she has any friends or family that can come in and help her.

Demonstrate ways that the client can comfort her baby. The client may need the nurse to demonstrate how to comfort the baby. The client may not have had this role modeling. Some negative feelings are normal in the first few days after birth and the nurse should be supportive if the mother does vocalize these feelings. It would be inappropriate to initiate a social work referral as the client is demonstrating positive coping and attachment behaviors at this time (holding her crying baby, lightly rubbing the baby's back). It would be inappropriate at this time to ask if any supports such as friends or family can come in to the hospital. A crying baby does not always indicate hunger--there could be multiple other reasons for this (e.g. gas pains, soiled diaper). Therefore, it is inappropriate for the nurse to assume that the baby is hungry and to tell the client that she must breastfeed.

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? Activate the code emergency response system. Take the neonate's temperature immediately according to hospital policy. Notify the physician that a cardiac consult is needed. Do nothing — acrocyanosis is normal in the neonate.

Do nothing — acrocyanosis is normal in the neonate. Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. Activating the code emergency response system, taking the neonate's temperature, and notifying the physician that a cardiac consult is needed are inappropriate actions.

The nurse is caring for a postterm newborn. What interventions will the nurse include in the client's plan of care? Select all that apply. Assess for hypoglycemia. Assess for respiratory distress. Examine the indirect Coombs test. Double-wrap the infant in blankets. Encourage early feedings.

Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Postterm newborns are at risk for hypoglycemia, meconium aspiration, and hypothermia, so the nurse should assess for all these disorders. Respiratory distress can occur after meconium aspiration, so the infant should be monitored closely for increased respiratory rates, grunting, retractions, and nasal flaring. Encouraging early feedings helps prevent hypoglycemia. Double-wrapping infants in blankets after they have been removed from the radiant warmer is done to prevent hypothermia. An indirect Coombs test would be related to jaundice.

The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? Formula feeding should be avoided to prevent interfering with the breast milk supply. More vigorous sucking is needed for a bottle feeding, so supplements should be avoided. Primarily, water supplements should be used to prevent jaundice. Formula supplements can provide nutrients not found in breast milk.

Formula feeding should be avoided to prevent interfering with the breast milk supply. Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established.Bottle supplements are not appropriate to prevent jaundice, although if neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding.Breastfeeding is considered the best nutritional source for infants.Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended, because the neonate needs increased fat in the diet. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next? Keep the neonate under the radiant warmer for 2 hours. Determine the length of the mother's labor. Obtain a blood sample to check for hypoglycemia. Notify the health care provider (HCP) immediately.

Notify the health care provider (HCP) immediately. Ortolani maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the HCP promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani's maneuver to APNs or HCPs. Determining the length of the mother's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take? Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. Perform a thorough physical assessment including checking rectal temperature. Place the neonate in an incubator, and notify the healthcare provider of the neonate's temperature. Encourage the mother to breastfeed the infant as soon as possible.

Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. The normal axillary temperature range for a neonate is 97.7 to 99.5°F (36.5 to 37.5°C). A temperature of 97.3°F (36.3°C) is slightly below normal. Because the neonate is full-term, it is safe to warm the neonate using conservative measures such as placing a cap on the head and trying skin-to-skin contact. There is no need to encourage feeding. Performing an assessment would require exposing the neonate and is not indicated. If this were an unstable or preterm neonate, an incubator may be recommended due to the underdeveloped thermoregulation in these neonates. Neonates with hypothermia experience bradycardia, which is defined as a heart rate less than 100 beats/minute.

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next? Keep the neonate in an isolation incubator for at least 2 hours. Place the infant skin to skin with the mother. Report the neonate's cyanosis to the primary care provider promptly. Ask the mother to massage the neonate's hands and feet.

Place the infant skin to skin with the mother. The neonate is demonstrating acrocyanosis, a normal finding evidenced by bluish hands and feet due to the neonate being cold or poor perfusion of the blood to the periphery of the body. The most appropriate action is to place the neonate skin to skin with the mother if stable, wrap the neonate in a warm blanket, or place the neonate under a radiant warmer. Massaging the extremities is inappropriate because it will not help to improve the circulation. Keeping the neonate in an isolation incubator is not warranted because acrocyanosis is not an infection but rather a manifestation of the neonate's sluggish peripheral circulation. Because acrocyanosis is a normal finding, notifying the primary care provider is not necessary.

The nurse is teaching the mother of a newborn to develop her baby's sensory system. To further improve the infant's most developed sense, what should the nurse instruct the mother to do? Place the newborn about 12 inches (30.5 cm) from maternal face for best sight. Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. Give infant formula with a sweetened taste to stimulate feeding. Speak in a high-pitched voice to get the newborn's attention.

Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn the eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.

The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. What nursing action should the nurse take next? Place the neonate in reverse Trendelenburg position. Note and tell the health care provider (HCP) when rounds are made. Take the neonate's blood pressure in all four extremities. Call for a cardiac consult.

Take the neonate's blood pressure in all four extremities. The next nursing action in this situation would be to assess the blood pressure in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency, and the HCP needs to be notified as soon as the blood pressure data has been collected. Generally, prescribing a HCP consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities.

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Notify the medical director of the physician's negligence. Inform the physician and ask the physician to quickly complete the procedure. Continue assisting with the circumcision and ask the mother to sign the consent form after the procedure.

Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Parents have the legal right to decide whether their son is circumcised. The nurse and physician should always check the medical record for a signed informed consent form before beginning any procedure. It's unacceptable for the nurse to ask for consent after the procedure. Quickly completing the circumcision is also unacceptable because an informed consent form wasn't signed. Both the nurse and physician were negligent for not checking for a signed informed consent form.

The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? The associated chordee is difficult to remove during circumcision. The infant is too small to have a circumcision. The foreskin is used to repair the deformity surgically. The meatus can become stenosed, leading to urinary obstruction.

The foreskin is used to repair the deformity surgically. The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life.

While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan? The neonate has difficulty coordinating sucking, swallowing, and breathing. Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia. This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress. A high-calorie formula, presently needed at this time, is more easily delivered via gavage.

The neonate has difficulty coordinating sucking, swallowing, and breathing. Before 32 weeks' gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle-feeding. Bottle-feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feeding prevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment.

Which statement describes the rationale for administering vitamin K to every neonate? The neonate lacks intestinal flora to make the vitamin. Neonates don't receive the clotting factor in utero. The drug prevents the development of phenylketonuria (PKU). It boosts the minimal level of vitamin K found in the neonate.

The neonate lacks intestinal flora to make the vitamin. Neonates are at risk for bleeding disorders during the first week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease.

After the newborn has been stabilized in the transition nursery, the nurse brings the newborn to the parents to room-in. What would be an indication to the nurse that there may be a problem with the parents bonding with their newborn? The parents are ambivalent about breastfeeding. The parents request that the newborn remain in the nursery. The parents seem concerned that the newborn's hands are blue. The parents need instruction on how to diaper the newborn.

The parents request that the newborn remain in the nursery. Bonding between the newborn and the parents starts shortly after birth when the parents cradle their newborn and gently stroke the newborn with their fingers. The parents should have the opportunity for skin-to-skin contact. The newborn can be swaddled to provide a sense of security and comfort. Concerned parents will exhibit feelings about the newborn's condition, weight, and general well-being. Many parents will not want their newborn to be taken to a transition nursery and instead want the child to stabilize in the room with them. The nurse would be concerned if the parents did not want their newborn in their room, did not hold the newborn, or asked someone else to change the diaper. It is a normal response for new parents to have difficulty with diaper changes, especially if it is a first-time parent. The nurse could use such opportunities to educate the parents about bonding and address any concerns the parents may have.

Parents of a neonate who is 32 weeks of age ask the nurse, "Why does he have a feeding tube in his nose?" What is the nurse's best response? The infant needs extra fluids to prevent dehydration. There is no sucking reflex at this gestational age. The sucking, swallowing, and breathing are not coordinated. The stomach cannot digest formula or breast milk at this time.

There is no sucking reflex at this gestational age. The sucking, swallowing, and breathing are not coordinated. At 32 weeks' gestation, a neonate has limited ability to coordinate sucking, swallowing, and breathing. The sucking reflex is present at 32 weeks' gestation, but the neonate cannot coordinate the reflex with swallowing and breathing. The stomach has the capacity for digestion at this gestational age. There are no indications that this neonate is dehydrated.

Which finding in an infant with a myelomeningocele should be reported to the health care provider (HCP) as a sign of increased intracranial pressure? a high-pitched cry overflow voiding only minimal lower extremity movement a fontanel that bulges with crying

a high-pitched cry A Chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus. This is a common problem in infants with myelomeningocele and will require surgical intervention with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the presence of a Chiari malformation and requires further evaluation. Minimal movement of the lower extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with crying.

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position? left side, with the neck slightly flexed abdomen, with the head down back, with the neck slightly extended back, with the head turned to the left side

back, with the neck slightly extended When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffing" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly flexing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask.

A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate hepatitis. sepsis. drug dependence. hypoglycemia.

drug dependence. Hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness are classic symptoms of drug dependency that usually appear within the first 24 hours after birth. Sepsis is indicated by temperature instability and tachycardia. Hepatitis will manifest as jaundice. Hypothermia, muscle twitching, diaphoresis, and respiratory distress may be signs of hypoglycemia.

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication? esophageal stricture speech problems recurrent mild diarrhea with dehydration gastric ulcers

esophageal stricture Dilatation at the anastomosis site is needed during the first years of childhood in about 50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with dehydration is not likely to develop with this surgery. Speech problems can occur if other abnormalities are present to produce them; the larynx and structures of speech are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor weight gain may be noted, but gastric ulcers should not develop from surgery to repair TEF.

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age? prominent creases on the soles and heels firm cartilage to the edge of the ear pinna fine, downy hair over the upper arms and back elbows brought to chest midline with resistance past the midline

fine, downy hair over the upper arms and back Lanugo (fine, downy hair) covers the entire body until about 20 weeks' gestation, when it begins to disappear from the face, trunk, and extremities, in that order. Lanugo is a consistent finding in preterm neonates.Firm cartilage to the edge of the ear pinna is a physical characteristic found in neonates born at term.The ability to bring elbows to the midline of the chest with resistance past midline, also known as the scarf sign, is a physical characteristic found in neonates born at term. At 30 weeks' gestation, there is no resistance and the elbow can be moved easily past midline.Creases on the soles and heels are physical characteristics found in neonates born at term. A preterm neonate would exhibit few sole creases.

A nursery nurse just received the shift report. Which neonate should the nurse assess first? six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation two-day-old term neonate in an open bassinette four-hour-old term neonate with jaundice twelve-hour-old term neonate who is small for gestational age

four-hour-old term neonate with jaundice The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.

A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant? passage of meconium jaundice hypoglycemia failure to thrive

hypoglycemia A large-for-gestational-age infant is at risk for hypoglycemia due to the possibility of a mother having diabetes (may or may not be diagnosed or related to gestation). The fetus makes insulin in response to the blood glucose that crosses the placenta; after birth, the fetus continues to make insulin even though high maternal blood glucose is no longer present. The result is neonatal hypoglycemia.The nurse will continue to monitor for passage of meconium in the newborn, but it may take several hours and is not a priority at this time.While nurses assess amniotic fluid for meconium so they can suction the airway at birth and attempt to prevent meconium aspiration of the newborn, this infant is already at least 5 minutes of age and breathing (according to the Apgar scores). The infant may develop jaundice, or failure to thrive, but there is no information to suggest these findings at this time.

A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? hypertension hypoglycemia hyperglycemia arrhythmia

hypoglycemia Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as the neonate's body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.

The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 9 lb (4,082 g). Assessing for which signs and symptoms should be a priority in this neonate? anemia delayed meconium elevated bilirubin hypoglycemia

hypoglycemia Postmature neonates commonly have difficulty maintaining adequate glucose reserves and usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications result primarily from a combination of advanced gestational age, placental insufficiency, and continued exposure to amniotic fluid. Delayed meconium is not associated with postterm gestation. Hyperbilirubinemia occurs in term neonates as well as postterm neonates, but unless there is an Rh incompatibility it does not develop until after the first 24 hours of life.

When assessing a neonate 1 hour after birth, the nurse notes acrocyanosis of both feet and hands, measures an axillary temperature of 95.5°F (35.3°C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which assessment would be the most concerning for the nurse? hypoxia bradypnea tachycardia hypothermia

hypothermia The neonate's normal axillary temperature should range from approximately 97.7°F to 99.5°F (36.5°C to 37.5°C). A temperature of 95.5°F (35.3°C) is very low. When the temperature drops, the neonate is at risk for hypothermia, respiratory distress, and hypoglycemia. The normal respiratory rate for a newborn is 30 to 60 breaths/minute while resting. It can increase with crying, and it will increase if hypothermia develops. This neonate would have tachypnea instead of bradypnea. The normal heart rate for a newborn is 110 to 160 beats/minute, so 110 beats/minute would be a normal finding and not tachycardia. All neonates have acrocyanosis of the hands and feet in the first few hours of life; this would not indicate hypoxia.

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem? hiatal hernia pyloric stenosis esophageal atresia diaphragmatic hernia

pyloric stenosis Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis. If the condition progresses without surgical intervention, the neonate will become dehydrated and develop metabolic alkalosis. Signs of esophageal atresia include coughing and regurgitation with feedings. Diaphragmatic hernia, a life-threatening event in which the abdominal contents herniate into the thoracic cavity, may be evidenced by breath sounds being heard over the abdomen and significant respiratory distress with cyanosis. Signs of hiatal hernia include vomiting, failure to thrive, and short periods of apnea.

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth? fluctuating body temperature fluctuating blood glucose results peripheral and circumoral cyanosis respiratory distress

respiratory distress One of the most crucial adaptations the newborn makes at birth is adjusting from a fluid-filled intrauterine environment to a gaseous extrauterine environment. The fluid from the intrauterine life environment must be removed so the infant can breathe. Passage through the birth canal allows intermittent compression of the thorax, which helps eliminate the fluid. If a mother has a cesarean birth, this compression does not occur, and transient tachypnea (respiratory rate above 60) can develop. Unstable blood sugars, poor thermoregulation, and peripheral and circumoral cyanosis (acrocyanosis) are associated with all newborns and not necessarily related to cesarean delivery.

The nurse is caring for a preterm neonate in the neonatal intensive care unit receiving enteral feedings. The nurse notes an increase in respiratory rate, increase in regurgitation of feeding solution, and moderate abdominal distention. What action does the nurse take based on these findings? notify the healthcare provider check the feeding tube placement stop the enteral feeding document findings and reassess in 15 to 20 minutes

stop the enteral feeding Necrotizing enterocolitis (NEC) is an inflammation of the bowel that occurs most often in preterm neonates who are receiving enteral feedings. The cause of the condition is not well understood, but the nurse should recognize the risk in this neonate and immediately stop the enteral feeding. Once this is done, the nurse ensures intravenous access is available, completes additional relevant assessments and notifies the healthcare provider of the findings. The nurse should not wait to complete these steps as NEC can quickly progress to sepsis and other complications. Improper placement of the feeding tube would not cause all the symptoms presented, so the nurse's focus should be NEC.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? thin, wasted appearance descended testicles numerous scrotal rugae abundance of scalp hair

thin, wasted appearance The premature neonate characteristically exhibits a thin, wasted appearance.The premature neonate commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse? "Hold the bottle vertically so that the milk flows easily and the baby does not need to suck hard." "Keep the nipple full of milk throughout the feeding." "Burp the newborn only after the baby has finished the bottle." "Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks."

"Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks." Paced bottle feeding allows the premature infant to have more control with feeding and mimics more natural feeding. The baby can pause and take a break when needed. The bottle is held nearly horizontal when it's in the infant's mouth. This way the milk won't pour into the newborn as it would with holding the bottle vertically or keeping the nipple full of milk. The baby should be burped at least once during the feeding to remove air bubbles.

The nurse is teaching a group of new parents about car seat safety. The nurse would know education has been effective when a parent makes which statement? "I can use a front-facing car seat when my baby reaches one year of age and 20 pounds." "I can buy a used car seat as long as it was manufactured within the past 15 years." "My baby can ride in the front seat facing forward if the airbag is safe for children." "I can use a front-facing car seat when my baby reaches the size limit of the rear-facing seat."

"I can use a front-facing car seat when my baby reaches the size limit of the rear-facing seat." The current recommendation for car seat safety is for children to stay rear-facing until they exceed the size limit of their rear-facing seats. Often seats allow for rear-facing until the child weighs 40 pounds, and it is recommended to keep children rear-facing as long as possible. The car seat should be tethered, and the infant should be secure with the shoulder straps across the chest. Parents should be instructed to refer to the recommendations of the car seat manufacturer. Children should not be placed in the front seat with an airbag. It is not recommended that parents buy used car seats, but if they do, seats should be less than 10 years old.

A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she makes which statement? "The way my baby's face looks now will stay that way." "My baby will be fine soon after we are home." "I may need some help coping with my newborn." "My baby may be irritable as a newborn."

"My baby will be fine soon after we are home." Changes seen in the facial features of newborns with fetal alcohol syndrome remain that way. These include epicanthal folds, whorls, irregular hair, cleft lip or palate, small teeth, and lack of philtrum. Newborns with fetal alcohol syndrome are usually difficult to calm and frequently cry for long periods of time. Parents do need assistance with caring for themselves and their infants, particularly with continued alcohol use. A supportive family or support systems are essential. The problems seen with this newborn do not go away and remain with the infant throughout life and are compounded when the child begins to develop mentally.

When performing discharge teaching with the parents of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, which parent statement about the child's prognosis indicates teaching has been successful? "My child will need extra fluids to prevent constipation." "My child will probably always need a high-fiber diet." "My child has a good chance of being potty trained." "My child will need to wear protective pads until puberty."

"My child has a good chance of being potty trained." Children who undergo surgical correction for low anorectal anomalies as infants usually are continent. Fecal continence can be expected after successful correction of anal membrane atresia. Therefore, this child probably has a good chance of being potty trained and will not need to wear protective pads. Extra fluids and a high-fiber diet are not required to prevent constipation. Children with high anorectal anomalies may or may not achieve continence.

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate? "The presence of vernix affects the newborn's immune system." "The vernix should be a thicker coating for a newborn." "The vernix is difficult and painful to remove from a newborn." "The vernix indicates a different gestational age than expected."

"The vernix indicates a different gestational age than expected." 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 post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

After teaching the parent of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the parent describes the condition in which way? "A part of the bowel is on the outside without anything covering it." "The lower bowel is lacking certain nerves to allow normal function." "There is a blind upper pouch and an opening from the esophagus into the airway." "The muscle below the stomach is too tight, causing the baby to vomit forcefully."

"There is a blind upper pouch and an opening from the esophagus into the airway." Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.

The nurse is instructing the mother of a newborn about administering erythromycin ointment. Which statement made by the mother demonstrates that the instruction was effective? "This helps my baby to start to produce clotting factors." "This will prevent my baby from having another vaccine in the future." "This prevents growth of group beta strep in my baby." "This is placed in both eyes to prevent infection."

"This is placed in both eyes to prevent infection." Vitamin K (phytonadione) helps with clotting factors. The newborn has no flora in the colon to develop clotting factors. Erythromycin ointment is placed the eyes to prevent infection in the eyes from exposure during birth. Hepatitis B vaccine can be given directly after birth and will eliminate another vaccine injection in the newborn's future. Group beta strep infection is not treated with erythromycin ointment.

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? "Our baby should have 1 to 3 soft, formed stools a day." "We should weigh our baby daily to make sure he is gaining weight." "The baby should burp during and after each feeding with no projective vomiting." "Our baby will require feedings through the night for several weeks or months after birth."

"We should weigh our baby daily to make sure he is gaining weight." Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Therefore, if the parents state they plan to weigh their baby daily, more teaching is required. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which information? "A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." "More than 50% of neonates born to mothers who are positive for HIV will be positive at 18 months of age." "An enlarged liver at birth generally means the neonate is HIV positive." "We will test your baby now, but testing will need to be repeated for an accurate diagnosis."

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis." New recommendations state that virologic diagnostic testing at birth should be considered for infants at high risk of HIV infection, but it may take several months before an accurate diagnosis can be made. New guidelines suggest that infants should be tested at 2 to 3 weeks, 1 to 2 months, and again 4 to 6 months. It is estimated that 15% to 30% of all HIV-positive mothers without treatment will give birth to HIV-positive infants. With appropriate drug intervention to the mother during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infection. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonucleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the first month.

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents? Ask the community health nurse to visit the family. Arrange a meeting between the health care team and the parents to develop a care plan. Provide written care instructions for the parents. Help the parents schedule a follow-up appointment with the pediatrician before discharge.

Arrange a meeting between the health care team and the parents to develop a care plan. A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism? beta-hemolytic streptococcus Staphylococcus aureus Chlamydia trachomatis Escherichia coli

Chlamydia trachomatis The use of erythromycin ophthalmic ointment prevents blindness from gonococcal organisms and C. trachomatis. This ointment usually is less expensive than tetracycline.Beta-hemolytic streptococcus, E. coli, and S. aureus can cause a generalized infection in the neonate. However, these organisms typically are not responsible for causing neonatal blindness.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first? Contact the neonatal resuscitation team. Start mouth-to-mouth resuscitation. Raise the neonate's head and pat the back gently. Clear the neonate's airway with suction or gravity.

Clear the neonate's airway with suction or gravity. If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction.Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway.Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway.Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.

The nurse is assessing a newborn (view the figure). What should the nurse expect the infant to do? Lift the torso. Turn the head to the left side. Extend the arms. Close the fingers around the nurse's hands.

Close the fingers around the nurse's hands. The nurse is assessing the newborn's grasp reflex. If the reflex is present, the newborn will close the fingers around the nurse's hands. Placing the nurse's fingers in the newborn's hands will not cause the infant to turn the head or extend the arms. The newborn does not have sufficient muscle control to lift the torso.

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material is characterized by: usually occurring prior to a feeding. a brownish color. one-time occurrence during feeding. a curdled appearance.

a curdled appearance. Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and occurs during or immediately after feeding. Vomiting is unrelated to a feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 mL. Vomited material is typically white and curdled in appearance. A brownish color suggests old blood. Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.

While making a home visit to a primiparous client and her 3-day-old infant, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which information about baby powder should the nurse relate to the mother? It may cause pneumonia to develop. It keeps the diaper from adhering to the skin. It helps prevent diaper rash. It can result in allergies later in life.

It may cause pneumonia to develop. The nurse should inform the mother that baby powder can enter the neonate's lungs and result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is frequent diaper changing and keeping the neonate's skin dry. The disposable diapers have moisture-collecting materials and generally do not adhere to the skin unless the diaper becomes saturated. Typically, allergies are not associated with the use of baby powder in neonates.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? Check the rectal temperature every 8 hours. Offer feedings every 4 hours. Keep the neonate's eyes completely covered. Use a regular diaper on the neonate.

Keep the neonate's eyes completely covered. To prevent eye damage from phototherapy, the eyes must remain covered at all times while under the lights. The eye patches can be removed when the neonate is held out of the lights by the parents for feeding. Instead of a regular diaper, a "string" diaper or disposable face mask may be used to help contain loose stools, while allowing maximum skin exposure. Feeding formula or breast milk every 2 to 3 hours is recommended to prevent hypoglycemia and to encourage gastrointestinal motility. Because the phototherapy lights can overheat the neonate, the temperature should be checked by the axillary route every 2 to 4 hours.

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding? port wine stain Mongolian spot cafe au lait spots Harlequin's sign

Mongolian spot Mongolian spots are gray, blue, or black marks that are found most frequently on the sacral area but also may be on the buttocks, arms, shoulders, or other areas. No treatment is necessary because these usually fade or disappear during the first few years of life.Harlequin's sign, manifested as one side of the body turning a deep red color, occurs when blood vessels on one side of the body constrict while those on the other side of the body dilate. The observance of Harlequin's sign should be documented and reported.Port-wine stains, flat purple-red sharply demarcated areas, or hemangiomas, dark red color lesions, or vascular tumors, are nevi flammeus and do not disappear with time.Cafe au lait spots are flat, patchy, light brown areas.

A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which interventions will the nurse include in the infant's plan of care? Select all that apply. Watch for apnea lasting longer than 20 seconds. Plan for an early discharge home with mother. Monitor for temperature instability. Assess for signs of respiratory distress. Ensure that the first bowel movement is within the first 12 hours.

Monitor for temperature instability. Watch for apnea lasting longer than 20 seconds. Assess for signs of respiratory distress. GBS can be transmitted from the mother to newborn during birth; this can result in the newborn developing septicemia. The newborn will be kept 24-48 hours to monitor for development of a GBS infection. Signs of GBS infection are similar to respiratory distress accompanied by temperature instability. Apnea lasting 20 seconds or longer may also indicate infection. The first bowel movement is unrelated to GBS infection.

Which characteristic should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)? Neonates are commonly lethargic. Neurologic disorders are common. The mortality rate is 70% unless treated. The IQ scores are usually average.

Neurologic disorders are common. Neurologic disorders are common in neonates with FAS. Speech and language disorders and hyperactivity are common manifestations of central nervous system dysfunction. Mild to severe intellectual disability and feeding problems also are common. Delayed growth and development is expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mortality rate, and there is no treatment for FAS, but early intervention improves client outcomes.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate? Document these findings as minor deviations. Ask the mother to consent to genetic studies. Explain these deviations to the newborn's mother. Notify the health care provider (HCP) immediately.

Notify the health care provider (HCP) immediately. A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the HCP immediately. The HCP should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated? Draw a complete blood count (CBC) with differential and feed the infant. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis.

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate? Withhold medications until liver function improves. Dress the neonate in loose-fitting clothing. Place the isolette close to the nurse's station. Place the isolette in a quiet area of the nursery.

Place the isolette in a quiet area of the nursery. The neonate experiencing drug withdrawal should be placed in a quiet area of the nursery to minimize stimuli; the nurses' station is typically not a quiet area. The neonate should be swaddled to prevent him from stimulating himself with movement. Medications should be administered as needed.

Which finding is considered normal in the neonate during the first few days after birth? weight gain of 25% weight loss of 25% weight loss then return to birth weight birth weight of 4½ to 5½ lb (2,000 to 2,500 g)

weight loss then return to birth weight Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

A neonate with heart failure is being discharged home. When teaching the parents about the neonate's nutritional needs, what should the nurse explain? The formula should be low in sodium. Decreased activity level should reduce the need for additional calories. The neonate may need a more calorie-dense formula. Fluids must be restricted.

The neonate may need a more calorie-dense formula. Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP) .

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. The neonate's toes do not fan out when soles of the feet are stroked. The neonate does stepping movements when held upright with sole of foot touching a surface. The neonate turns toward the nurse's finger when she touches the neonate's cheek. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking. The neonate grasps the nurse's finger when she puts it in the palm of the neonate's hand.

The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking. Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not flare when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the flaring of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek.

When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to use which intervention? Feed the neonate extra, high-calorie formula. Tightly swaddle the neonate. Keep the neonate in a brightly lit environment. Touch the baby only when he is crying.

Tightly swaddle the neonate. A neonate undergoing cocaine withdrawal is irritable, often restless, difficult to console, and often in need of increased activity. It is commonly helpful to swaddle the neonate tightly with a blanket, offer a pacifier, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastrointestinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to only when he or she is crying will not aid the bonding process between mother and neonate. Frequent holding and touching are permissible.

A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area that the nurse would touch to elicit a plantar grasp reflex.

To elicit a plantar grasp reflex, the nurse would touch the sole of the foot near the base of the digits, causing flexion or grasping. This reflex disappears around age 9 months.

The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?

When assessing the incurving of the trunk tests for automatic reflexes in the newborn, the nurse places the infant horizontally and in a prone position with one hand, and strokes the side of the newborn's trunk from the shoulder to the buttocks using the other hand. If the reflex is present, the newborn's trunk curves toward the stimulated side. Answer 2 shows a figure for testing for a stepping response. Answer 3 shows a figure for testing for a tonic neck reflex. Answer 4 shows a figure for testing for the Moro (startle) reflex.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that a cephalohematoma occurs with a birth that required instrumentation. caput succedaneum occurs primarily with a prolonged second stage of labor. caput succedaneum occurs primarily with primigravidas. a cephalohematoma doesn't cross the suture lines.

a cephalohematoma doesn't cross the suture lines. Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the neonate's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)? abdominal distention jaundice appearing on the face and chest the presence of 1 mL of gastric residual before a gavage feeding an increase in bowel peristalsis

abdominal distention Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.

While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? Turner's syndrome renal disorders ambiguous genitalia Potter's syndrome

ambiguous genitalia An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present.Renal disorders are associated with absence of a kidney and oliguria.Potter's syndrome is a fatal condition involving renal agenesis and facial deformities.Turner's syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem? esophageal varices ABO incompatibility Rh isoimmunization biliary atresia

biliary atresia Jaundice that persists past the third or fourth day of life and pale, light stools are associated with biliary atresia. Alkaline phosphatase levels will also be elevated. Surgical intervention is necessary to remove the blockage. Rh isoimmunization and ABO incompatibility are associated with neonatal anemia as the red blood cells are hemolyzed by the antibodies. Esophageal varices are associated with cirrhosis of the liver and large amounts of bleeding when the vessels rupture. The child with esophageal varices will exhibit manifestations of anemia such as pallor and may experience hemorrhage and shock.

After a vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the health care provider (HCP) based on the analysis that this may be indicative of which anomalies? cardiovascular anomalies facial anomalies musculoskeletal anomalies respiratory anomalies

cardiovascular anomalies Normally, the umbilical cord has two umbilical arteries and one vein. When a neonate is born with only one artery and one vein, the nurse should notify the HCP for further evaluation of cardiac anomalies. Other common congenital problems associated with a missing artery include renal anomalies, central nervous system lesions, tracheoesophageal fistulas, trisomy 13, and trisomy 18. Respiratory anomalies are associated with dyspnea and respiratory distress; musculoskeletal anomalies include fractures or dislocated hip; and facial anomalies are associated with fetal alcohol syndrome or Down syndrome, not a missing umbilical artery

During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indomethacin. What is the expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosis? increased gastrointestinal function decreased bleeding time increased renal output closure of a patent ductus arteriosus

closure of a patent ductus arteriosus The indication for the use of indomethacin is to close a patent ductus arteriosus. Adverse effects include decreased renal blood flow, platelet dysfunction with coagulation defects, decreased GI motility, and an increase in necrotizing enterocolitis. Thus, increased bleeding time, decreased gastrointestinal function, and decreased renal output would be expected outcomes after the administration of indomethacin.

The neonate in the nurse's care has a pneumothorax. The nurse knows the signs of early decompensation and to observe carefully for changes in which assessments? Select all that apply. heart rate blood pressure temperature color urinary output

color heart rate blood pressure The pneumothorax may affect cardiac output, thus affecting perfusion causing a decrease in blood pressure and changes in color from pallor to cyanosis. As the neonate attempts to compensate, bradycardia or tachycardia may be exhibited. A change in temperature and urinary output are very late signs of decompensation.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, the nurse should expect to include which measure in the plan to help prevent obesity? using a large-bowled spoon for feeding solid foods during the first several months decreasing the amount of formula or breast milk intake as solid food intake increases introducing the infant to the taste of vegetables by mixing them with formula or breast milk mixing cereal and fruit in a bottle when offering solid food for the first few times

decreasing the amount of formula or breast milk intake as solid food intake increases Decreasing the amount of formula given as the infant begins to take solids helps prevent excess caloric intake. Because the infant is receiving calories from the solid foods, the formula no longer needs to provide the infant's total caloric requirements. Mixing vegetables with formula or breast milk does not allow the child to become accustomed to new textures or tastes. Solid foods should be given with a spoon, not in a bottle. Using a bottle with food allows the infant to ingest more food than is needed. Also, the infant needs to learn to eat from a spoon. A small-bowled spoon is recommended for infants because infants have a tendency to push food out with the tongue. The small-bowled spoon helps in placing the food at the back of the infant's tongue when feeding.

The charge nurse in the newborn nursery and an unlicensed assistive personnel (UAP) are working together on a shift. Under their care are eight babies rooming in with their mothers, and one infant is in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply. document feedings of infants newborn admission vital signs on all stable infants bath and initial feeding for new admission record voids/stools tube feeding

document feedings of infants record voids/stools vital signs on all stable infants The role of the UAP allows this member of the health care team to take vital signs on clients, record feedings, and voids and stools of infants according to hospital guidelines. The newborn assessment is completed by a licensed care provider as is the tube feeding. Bathing of the newborn is within the scope of practice for the UAP, but the initial assessment of patency of the gastrointestinal tract, which is initiated by the first feeding, is within the scope of licensed care providers. If there is a trachea esophageal fistula, this is the time when it may become evident.

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to obtain a family medical history. explain the NICU visiting policy for the mother and family. question the mother about her preterm labor. enhance bonding by pointing out the neonate's features.

enhance bonding by pointing out the neonate's features. Pointing out neonate's features to the mother enables the mother to begin to bond with him. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the mother about her preterm labor don't take priority over enhancing maternal bonding.

While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the health care provider (HCP)? expiratory grunt respiratory rate of 45 breaths/min red reflex in the eyes prominent xiphoid process

expiratory grunt An expiratory grunt is significant and should be reported promptly because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts. The presence of a red reflex in the eyes is normal. An absent red reflex may indicate congenital cataracts. A respiratory rate of 45 breaths/min and a prominent xiphoid process are normal findings in a term neonate.

Which action is the best precaution against transmission of infection? eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection strict isolation for a neonate whose mother has human immunodeficiency virus (HIV) eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Mothers can transmit gonorrhea during the birth process; untreated, it can cause serious eye damage to the neonate. A neonate whose mother has hepatitis B should receive hepatitis B immunoglobulin within 12 hours of birth, not eye prophylaxis. CMV doesn't require strict isolation; however, the neonate may be treated with I.V. antivirals. HIV is transmitted via blood and body fluids. Contact isolation, not strict isolation, is appropriate.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use? helps maintain a rhythmic breathing pattern reducing tachypnea helps lungs remain expanded after the initiation of breathing improving oxygenation assists with ciliary body maturation in the upper airways eliminating mucous promotes mucous production lubricating the respiratory tract

helps lungs remain expanded after the initiation of breathing improving oxygenation Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal? high-pitched cry sluggishness bradycardia hypocalcemia

high-pitched cry Manifestations of opiate withdrawal in the neonate, known as neonatal abstinence syndrome (NAS), include an increased central nervous system irritability, gastrointestinal symptoms, and metabolic, vasomotor, and respiratory disturbances. These signs usually appear within 72 hours and persist for several days. Infants have diarrhea not constipation. They typically display increased sucking behaviors, but are poor feeders. Vomiting is common with babies who have NAS.

A mother who gave birth some three hours ago asked the nurse why her baby is so difficult to keep awake. The nurse informs the mother that this behavior indicates normal progression into the sleep cycle. probable hypoglycemia. normal progression into a period of neonatal reactivity. a physiologic abnormality.

normal progression into the sleep cycle. Typically, it's difficult to awaken any neonate 3 hours after birth. This finding suggests normal progression into the sleep cycle. During this period, the neonate shows minimal response to external stimuli. Hypoglycemia is characterized by irregular respirations, apnea, and tremors. Periods of neonatal reactivity are characterized by alertness and attentiveness.

A neonate born by cesarean at 42 weeks' gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? decreased cardiac output hypoglycemia ineffective airway clearance hyperthermia

hypoglycemia Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the postterm neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the postterm neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean section, which is not considered a difficult birth.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? hydrocele hypospadias epispadias phimosis

hypospadias The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder exstrophy.

Which nursing intervention is most important when working with neonates who are suspected of having congenital hypothyroidism? allowing rooming in encouraging fluid intake identifying the disorder early promoting bonding

identifying the disorder early The most important nursing intervention is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. What would be the priority problem for this neonate? hyperglycemia impaired skin integrity impaired gas exchange risk for impaired patent-infant-child attachment

impaired gas exchange The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing adequate respirations is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, then risk for impaired parent-infant-child attachment may be appropriate once the airway is established.

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find congenital defects such as limb anomalies. irritability and poor sucking. lethargy 2 days after birth. a flattened nose, small eyes, and thin lips.

irritability and poor sucking. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in neonates with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is too large. is appropriate is positioned too low. is too small.

is appropriate The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose.

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is peripheral acrocyanosis. bradycardia. lethargy. jaundice.

lethargy. Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

At a home visit, the nurse assesses a neonate born vaginally at 41 weeks' gestation 5 days ago. Which finding warrants further assessment? frequent hiccups loose, watery stool in diaper pink papular vesicles on the face dry, peeling skin

loose, watery stool in diaper A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate, compared with the adult. Frequent hiccups are considered normal in a neonate and do not warrant additional investigation. Pink papular vesicles (erythema toxicum) on the face are considered normal in a neonate and disappear without treatment. Dry, peeling skin is normal in a postterm neonate.

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress? abdominal breathing acrocyanosis respiratory rate of 54 breaths/minute nasal flaring

nasal flaring Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations, grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in neonates. Acrocyanosis (a bluish tinge to the hands and feet) is normal on the first day after birth.

A registered nurse on the neonatal unit appropriately uses the chain of command when notifying the unit manager of unresolved issues between the nursing unit and housekeeping personnel. e-mailing the housekeeping supervisor about a problem on the nursing unit. discussing unprofessional behavior of laboratory personnel with the laboratory manager. asking the unit manager to grant vacation requests.

notifying the unit manager of unresolved issues between the nursing unit and housekeeping personnel. The concept of chain of command requires that the nurse contact the nurse-manager for issues related to other departments; the nurse-manager should handle such issues. Contacting the laboratory manager, asking the unit manager to grant vacation requests, and e-mailing the housekeeping supervisor aren't appropriate uses of the chain of command.

Sick and preterm neonates who experience continuity of nursing care directly benefit from decreased hospital liability for professional malpractice. higher levels of professional satisfaction among nurses. higher levels of parent satisfaction with nursing care. nursing recognition of subtle changes in high-risk neonates' conditions.

nursing recognition of subtle changes in high-risk neonates' conditions. Continuity of care allows the nurse to observe subtle changes in a neonate's condition. Although nurses and parents experience higher levels of satisfaction and professional liability may decline, these results aren't direct benefits to the neonate.

A nurse is performing a neurologic assessment on a neonate. Which assessment finding would be normal for a neonate? positive Babinski's reflex let-down reflex doll's eyes "sunset" eyes

positive Babinski's reflex A positive Babinski's reflex is present in neonates and infants until approximately age 1. However, this reflex is abnormal in adults. Doll's eyes are a neurologic response noted in adults. The appearance of "sunset" eyes, in which the sclera is visible above the iris, results from cranial nerve palsies and may indicate increased intracranial pressure. A neonate's pupils normally react to light in the same way as an adult's.

A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity occurs by antibody transmission. develops rapidly and is temporary. results from exposure of an antigen through immunization or disease contact. may be transferred by mother to neonate.

results from exposure of an antigen through immunization or disease contact. Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it is temporary. Passive immunity may be transferred by mother to neonate.

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication? retinopathy of prematurity glaucoma cataracts ophthalmia neonatorum

retinopathy of prematurity High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict, then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness.Cataracts and glaucoma are congenital abnormalities in the neonate unrelated to oxygen therapy.Ophthalmia neonatorum is a gonorrheal infection of the eyes that is likely to occur if a mother has the gonorrheal organism in her birth canal.

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan? imbalanced nutrition: less than body requirements related to inadequate feeding hypothermia related to immature temperature regulation deficient fluid volume related to insensible fluid loss risk for injury related to hyperbilirubinemia

risk for injury related to hyperbilirubinemia Yellow sclerae indicate bilirubin deposits and possible hyperbilirubinemia. The nurse should add a diagnosis of risk for injury related to hyperbilirubinemia to the care plan because bilirubinemia may cause bilirubin encephalopathy (kernicterus). The assessment findings don't support a nursing diagnosis of imbalanced nutrition: less than body requirements related to inadequate feeding because neonates normally breast-feed every 2 to 3 hours. An axillary temperature of 98° F (36.7° C) is within normal limits for a neonate, eliminating hypothermia as a nursing diagnosis. Loss of up to 10% of birth weight is normal in neonates, making a diagnosis of deficient fluid volume inappropriate.

After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which agent? povidone-iodine solution antibacterial soap warm water diluted hydrogen peroxide

warm water After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone-iodine solution may cause stinging and burning, and therefore its use is not recommended.

While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this as which finding? stork bite newborn rash café au lait spot port-wine stain

stork bite Several irregularly shaped red patches, common skin variations in neonates, are termed stork bites. They eventually fade away as the neonate grows older. Port-wine stains are disfiguring darkish red or purplish skin discolorations on the scalp and face that may need laser therapy for removal. Newborn rash is typically generalized over the body, not localized to one body area, and is commonly raised. Café au lait spots are brown and typically found anywhere on the body. More than six spots or spots larger than 1.5 cm are associated with neurofibromatosis, a genetic condition of neural tissue.

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance? somatotropin progesterone surfactant testosterone

surfactant RDS, previously called hyaline membrane disease, is a developmental condition involving a decrease in lung surfactant leading to improper expansion of the lung alveoli. Surfactant contains a group of surface-active phospholipids, of which one component—lecithin—is the most critical for alveolar stability. Surfactant production peaks at about 35 weeks' gestation. This syndrome primarily attacks preterm neonates, although it can also affect term and postterm neonates. Altered somatotropin secretion is associated with growth disorders such as gigantism or dwarfism. Altered testosterone secretion is associated with masculinization. Altered progesterone secretion is associated with spontaneous abortion during pregnancy.

A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expect the newborn to exhibit? Select all that apply. effective latch to the breast easily consoled and comforted sensitive gag reflex hyperactivity and increased muscle tone tachypnea with excessive secretions

tachypnea with excessive secretions sensitive gag reflex hyperactivity and increased muscle tone Newborns exposed to drugs while in utero can have tachypnea, excessive secretions, a sensitive gag reflex, hyperactivity, and increased muscle tone. Newborns exposed to drugs while in utero will not be satisfied with breastfeeding or eating and are not easily consoled or comforted.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. the neonate voids once or twice every 24 hours. the neonate latches onto the areola and swallows audibly. the neonate breast-feeds four times in 24 hours.

the neonate latches onto the areola and swallows audibly. Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.

When developing a nursing care plan for an infant receiving phototherapy, the nurse should include what information in the plan of care? Select all that apply. eye protection thermoregulation allowing mother to hold infant as much as she wishes adequate skin exposure to phototherapy supplemental water between feedings

thermoregulation eye protection adequate skin exposure to phototherapy For phototherapy to be effective, the skin needs to be exposed to the light waves to allow for the conversion of bilirubin to water-soluble isomers that are excreted without further metabolism by the liver. Eye protection is necessary to prevent retinal damage. As infants are usually dressed only in a diaper for maximum skin exposure to the light, thermoregulation is a concern. The infants can be too cool or potentially overheat if the phototherapy lights are not positioned correctly. Most often mothers are allowed to hold their infants for feeding; there is usually a 30-minute time limit. In order for the phototherapy to be effective, the baby must be under the lights except for feedings. Water supplementation is not indicated as the baby needs the calories and nutrients that breast milk or formula provide. Extra water feedings will not prevent hyperbilirubinemia or decrease total serum bilirubin levels.

After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate displays which behavior? turns head to the left, extends left extremities, and flexes right extremities steps briskly when held upright near a firm, hard surface extends and abducts the arms and legs with the toes fanning open pulls both arms and does not move the chin beyond the point of the elbows

turns head to the left, extends left extremities, and flexes right extremities The tonic neck reflex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and flexes the right extremities. This reflex disappears in a matter of months as the neonatal nervous system matures. The stepping reflex is demonstrated when the infant is held upright near a hard, firm surface. The prone crawl reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski reflex.

The nurses teaches a parent to take a neonate's temperature with a disposable digital thermometer. Where does the nurse tell the parent to place the thermometer? into the neonate's ear under the neonate's tongue into the neonate's rectum under the neonate's arm

under the neonate's arm The correct method of assessing a neonate's temperature is to place the thermometer under the neonate's arm for an axillary reading.The oral route is not appropriate for obtaining the temperature in a neonate because the neonate is unable to close the mouth around the thermometer, thus leading to an inaccurate reading. Additionally, inserting a thermometer into a neonate's mouth may cause trauma to delicate tissues.Rectal temperatures are to be avoided in neonates because of the risk of injury to or perforation of the delicate rectal mucosa.Only a specialized tympanic membrane device should be used to obtain a temperature reading via the ear. Inserting a disposable digital thermometer into the neonate's ear may cause trauma to the delicate tissues.