The Neonate

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents? "Are you worried your baby might die?" "How can I arrange the baptism?" "Do you want to speak with the social worker?" "Would you prefer to wait for the surgery?"

"How can I arrange the baptism?"

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take? Continue with normal newborn care. Notify the health care provider of the finding. Provide an extra feeding for the infant. Wait and assess the skin color when the infant is over 24 hours old.

Notify the health care provider of the finding.

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. Do nothing — acrocyanosis is normal in the neonate. 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.

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

irritability and poor sucking.

A newborn baby has developed physiologic jaundice. The parents are concerned about the appearance of the newborn and ask the nurse about their concerns. Which of the following would be the most appropriate response by the nurse? "Your infant will most likely need to be admitted to the hospital. The baby has a condition known as jaundice." "Your infant is fine and there is nothing to worry about. Jaundice is very common." "You let us worry about your baby. This is a pretty critical time for her." "I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were 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.

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? drug withdrawal first period of reactivity a state of deep sleep respiratory distress

a state of deep sleep

A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. Notify the physician immediately. Ask the physician for an order to obtain cultures of both of the neonate's eyes. Obtain a nasal viral culture.

Ask the physician for an order to obtain cultures of both of the neonate's eyes.

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

"Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects."

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. Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. 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.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding? Call the physician and inform him of the finding. Tell the parents this is a normal finding for a neonate who was breech. Keep the neonate on nothing-by-mouth status and observe for seizures. Note the finding on the assessment record.

Note the finding on the assessment record.

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

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 explain the NICU visiting policy for the mother and family. enhance bonding by pointing out the neonate's features. obtain a family medical history. question the mother about her preterm labor.

enhance bonding by pointing out the neonate's features.

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? Determine the length of the mother's labor. Notify the health care provider (HCP) immediately. Keep the neonate under the radiant warmer for 2 hours. Obtain a blood sample to check for hypoglycemia.

Notify the health care provider (HCP) immediately.

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 sepsis. hepatitis. drug dependence. hypoglycemia.

drug dependence.

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner? Humidify the air being delivered. Cover the neonate's scalp with a warm cap. Record the neonate's temperature every 3 to 4 minutes. Assess the neonate's blood glucose level.

Humidify the air being delivered.

While caring for a client and their 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains the neonate's need for gavage feeding at this time instead of the client'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. A high-calorie formula, presently needed at this time, is more easily delivered via gavage. Gavage feedings can minimize the neonate's increased risk for developing hypoglycemia. This type of feeding, easily given in the isolette, decreases the neonate's risk for cold stress.

The neonate has difficulty coordinating sucking, swallowing, and breathing.

When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply. Their baby's eyes will be covered. The vital signs will need to be monitored frequently. Their baby will be fed through an orogastric tube. They will be able to visit and care for their baby. The baby will need to have the body covered at all times.

Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.

The nurse develops the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery. What intervention would be most helpful in facilitating parent-infant bonding? explaining to the parents that they can visit at any time encouraging the parents to hold their infant asking the parents to help monitor the infant's intake and output helping the parents plan for their infant's discharge

encouraging the parents to hold their infant

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. At what age does the nurse should tell the client to start modifying her child's diet? birth age 2 years age 5 years age 10 years

age 2 years

The newborn nurse has just received the shift report about a group of newborns and is to receive another admission in 30 minutes. To provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used. Move quickly from room to room, and assess all clients. Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. Check the room to which the new client will be admitted to ensure all supplies and equipment are available. Log on to the clinical information system, and determine if there are new prescriptions.

Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new prescriptions. Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

When the nurse accidentally bumps the bassinet, the neonate throws out their arms, opens their hands, and begins to cry. The nurse interprets this reaction as indicative of which reflex? Moro reflex Babinski reflex grasping reflex tonic neck reflex

Moro reflex

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 birth parents, 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 task(s) would the nurse assign to the UAP? Select all that apply. newborn admission vital signs of all stable infants tube feeding document feedings of infants record voids/stools bath and initial feeding for new admission

vital signs of all stable infants document feedings of infants record voids/stools

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? Call for a cardiac consult. Note and tell the health care provider (HCP) when rounds are made. Place the neonate in reverse Trendelenburg position. Take the neonate's blood pressure in all four extremities.

Take the neonate's blood pressure in all four extremities.

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

"Brain damage may occur if the molding does not resolve quickly."

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

Tightly swaddle the neonate.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first? Start mouth-to-mouth resuscitation. Contact the neonatal resuscitation team. 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.

On examination of a newborn client, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which nursing action is appropriate? Ask the maternal parent about any complications in pregnancy. Consider the finding as normal. Inform the health care provider about the condition. Put a dressing over the pigmented area.

Consider the finding as normal.

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 Escherichia coli Chlamydia trachomatis Staphylococcus aureus

Chlamydia trachomatis

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 vernix is difficult and painful to remove from a newborn." "The presence of vernix affects the newborn's immune system." "The vernix should be a thicker coating for a newborn." "The vernix indicates a different gestational age than expected."

"The vernix indicates a different gestational age than expected."

While changing her newborn's diaper, a mother states: "there is some bleeding from the vagina." Which is the nurse's appropriate response? "This is in response to your hormones and will stop within a week." "Your infant is dehydrated, which is why there is some bleeding in the diaper." "The wet wipes must be irritating the skin. I will call the healthcare provider." "Because the newborn's stool was runny, I doubt you can see any bleeding."

"This is in response to your hormones and will stop within a week."

After teaching a client about bottle-feeding, which client statement indicates the need for additional teaching? "Bottle-fed babies up to 6 months of age may gain as much as 1 oz (30 g) a day." "Iron-fortified formulas are usually recommended for newborns." "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."

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? "Don't worry. It's too soon to tell." "Chances are the baby will be okay because you don't have AIDS yet." "Your child may have acquired HIV in utero, but we won't know for sure until the child is older." "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."

The health care provider prescribes ampicillin 100 mg/kg per dose for a newly admitted neonate. The neonate weighs 1350 g (2.97 lb). How many milligrams should the nurse administer? Record your answer using one decimal place.

135 mg

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using one decimal place.

240 calories

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 mg

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit? A pregnant nurse shouldn't care for a neonate whose mother was positive for human immunodeficiency virus (HIV). A nurse with young children shouldn't care for a neonate whose mother has gonorrhea. A nurse with young children shouldn't care for a neonate with erythema toxicum. A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

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. 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.

Arrange a meeting between the health care team and the parents to develop a care plan.

While caring for the neonate of an HIV-positive birth parent, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse take first? Bathe the neonate. Place the neonate under a radiant warmer. Wash the injection site with povidone-iodine solution. Wait until the first dose of antiretroviral medication is given.

Bathe the neonate.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent? Continue feeding every 3 to 4 hours since the weight loss is normal. Contact the health care provider (HCP). 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.

Which action is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment? Place the neonate in an isolation area. Try to remove the specks with a wet washcloth. Attempt to obtain a sterile specimen on a swab. Continue monitoring because these spots are normal.

Continue monitoring because these spots are normal.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? Risk for aspiration related to nil orally status. Deficient knowledge related to ventilatory support. Deficient knowledge related to lack of exposure to apnea monitor. Deficient knowledge related to inability to cope.

Deficient knowledge related to lack of exposure to apnea monitor.

When developing the teaching plan for a primiparous client who is bottle-feeding their term neonate for the first feeding, what information should the nurse include? Fill the entire nipple of the bottle with formula. All term babies have well-developed sucking skills. Bubble the baby after 2 oz (60 mL) of formula has been taken. Propping of the bottle results in too much air being taken in by the baby.

Fill the entire nipple of the bottle with formula.

The client who is breastfeeding asks the nurse if they 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. Water supplements should be primarily used to prevent jaundice. Formula supplements can provide nutrients not found in breast milk. More vigorous sucking is needed for bottle-feeding, so supplements should be avoided.

Formula feeding should be avoided to prevent interfering with the breast milk supply.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel (UAP) has positioned the oxygen mask (view the figure). What does the nurse assessing the infant determine about the UAP's mask selection? It is appropriate for the neonate. The mask is too large. The mask is too small. The mask requires a soft cloth cover.

It is appropriate for the neonate.

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

Keep the neonate's eyes completely covered.

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. Place the neonate in an incubator, and notify the healthcare provider of the neonate's temperature. Perform a thorough physical assessment including checking rectal 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.

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during their pregnancy. What nursing intervention should the nurse implement when caring for a drug-exposed neonate? Assess vital signs including blood pressure every hour. Minimize environmental stimuli. Place the infant in a well-lighted area. Increase eye contact with the caregiver.

Minimize environmental stimuli.

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); the baby is breathing room air and is pink with acrocyanosis. The birth parent had membranes that were ruptured 26 hours before birth. What nursing action is most indicated? Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. Place a pulse oximeter, and request a prescription to draw blood cultures. Arrange a transfer to the neonatal intensive care unit with a diagnosis of possible sepsis. Draw a complete blood count (CBC) with differential, and feed the infant.

Place a pulse oximeter, and request a prescription to draw blood cultures.

A viable female neonate was delivered ten minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should: Move the infant away from cool window surfaces. Make certain the infant has no contact with cool surfaces. Dry the infant's skin with a towel. Position the infant away from drafts and cooling ducts.

Position the infant away from drafts and cooling ducts.

What is the best reason for assessing a neonate weighing 1500 g (1.5 kg) at 32 weeks' gestation for retinopathy of prematurity (ROP)? The neonate is at risk because of multiple factors. Oxygen is being administered at a level of 21%. The neonate was alkalotic immediately after birth. Phototherapy is likely to be prescribed by the primary health care provider.

The neonate is at risk because of multiple factors.

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 grasps the nurse's finger when she puts it in the palm of the neonate's hand. The neonate does stepping movements when held upright with sole of foot touching a surface. 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 turns toward the nurse's finger when she touches the neonate's cheek. The neonate displays weak, ineffective sucking.

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.

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 sucking, swallowing, and breathing are not coordinated. There is no sucking reflex at this gestational age. The stomach cannot digest formula or breast milk at this time. The infant needs extra fluids to prevent dehydration.

The sucking, swallowing, and breathing are not coordinated.

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? Wear protective gear near the isolation incubator. Visit but do not touch the neonate. Wash hands thoroughly before touching the neonate. Wear a mask when holding the neonate.

Wash hands thoroughly before touching the neonate.

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's mildly depressed a neonate who's moderately depressed a neonate who needs additional oxygen to improve the Apgar score

a neonate who's in good condition

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. adequate skin exposure to phototherapy allowing the birth parent to hold the infant as much as they wish eye protection supplemental water between feedings thermoregulation

adequate skin exposure to phototherapy eye protection thermoregulation

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? biliary atresia Rh isoimmunization ABO incompatibility esophageal varices

biliary atresia

A primiparous client has just given birth to a term infant. Which topic should the nurse teach the client about first? sudden unexplained infant death syndrome (SUIDS) breastfeeding/chestfeeding newborn medications infant sleep-wake cycles

breastfeeding/chestfeeding

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? increased muscle tone hyperbilirubinemia bulging fontanelles hyperactivity

bulging fontanelles

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? closure of a patent ductus arteriosus decreased bleeding time increased gastrointestinal function increased renal output

closure of a patent ductus arteriosus

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

four-hour-old term neonate with jaundice

The nurse develops a teaching plan for the parent 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? 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 thin cereal with juice during the first several months

decreasing the amount of formula or breast milk intake as solid food intake increases

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

fine, downy hair over the upper arms and back

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? assists with ciliary body maturation in the upper airways eliminating mucous helps maintain a rhythmic breathing pattern reducing tachypnea promotes mucous production lubricating the respiratory tract helps lungs remain expanded after the initiation of breathing improving oxygenation

helps lungs remain expanded after the initiation of breathing improving oxygenation

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? jaundice passage of meconium hypoglycemia failure to thrive

hypoglycemia

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

hypoglycemia

The nurse is caring for a primiparous client and their neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4082 g (4.1 kg). Assessing for signs and symptoms of which condition should be a priority in this neonate? anemia hypoglycemia delayed meconium elevated bilirubin

hypoglycemia

While assessing a male neonate whose parent desires that the infant 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? phimosis hydrocele epispadias hypospadias

hypospadias

After teaching a client about the neonate's positive Babinski reflex, the nurse determines that the mother understands the instructions when they say that a positive Babinski reflex indicates which condition? possible partial paralysis possible spinal cord defect immaturity of the central nervous system injury to the nerves innervating the legs

immaturity of the central nervous system

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the parent visits the neonate at 1 hour after birth, the nurse explains to the parent that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? increased use of glucose stores during a difficult labor and birth process interrupted supply of maternal glucose and continued high neonatal insulin production a normal response that occurs during the transition from intrauterine to extrauterine life increased pancreatic enzyme production caused by decreased glucose stores

interrupted supply of maternal glucose and continued high neonatal insulin production

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? hypertonia hyperactivity large size scaly skin

large size

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

nasal flaring

A registered nurse on the neonatal unit appropriately uses the chain of command when 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. e-mailing the housekeeping supervisor about a problem on the nursing unit.

notifying the unit manager of unresolved issues between the nursing unit and housekeeping personnel.

The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which area?

sides of heel

The nurse instructs a primiparous client about bottle-feeding their neonate. Which action demonstrates that the maternal parent has understood the nurse's instructions? placing the neonate on its back after the feeding bubbling the baby after 1 oz (30 ml) of formula putting three-quarters of the bottle nipple into the baby's mouth pointing the nipple toward the neonate's palate

placing the neonate on its back after the feeding

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a parent with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? degree of anemia in the neonate initial bilirubin level presence of maternal antibodies appropriate dose of Rho(D) immune globulin

presence of maternal antibodies

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? esophageal atresia pyloric stenosis diaphragmatic hernia hiatal hernia

pyloric stenosis

A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate? hypoglycemia jitteriness respiratory depression tachycardia

respiratory depression

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 respiratory distress peripheral and circumoral cyanosis fluctuating blood glucose results

respiratory distress

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 voids once or twice every 24 hours. the neonate breast-feeds four times in 24 hours. the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. the neonate latches onto the areola and swallows audibly.

the neonate latches onto the areola and swallows audibly.