The Neonate
A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? A) Bradycardia. B) Rapid eye movement. C) Seizures. D) Tachycardia.
A) Bradycardia. Reason: Because of vigorous suctioning, the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.
Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? A) Rewarm the neonate gradually. B) Rewarm the neonate rapidly. C) Observe the neonate hourly. D) Notify the physician when the neonate's temperature is normal.
A) Rewarm the neonate gradually. Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.
A woman who has recently immigrated from Africa who delivered a term neonate a short time ago requests that a "special bracelet" be placed on the baby's wrist. The nurse should: A) Tell the mother that the bracelet is not recommended for cleanliness reasons. B) Apply the bracelet on the neonate's wrist as the mother requests. C) Place the bracelet on the neonate, limiting its use to when the neonate is with the mother. D) Recommend that the mother wait until she is discharged to apply the bracelet.
B) Apply the bracelet on the neonate's wrist as the mother requests. Reason: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust. The neonate can wear the bracelet while with the mother or in the nursery. The bracelet can be used while the neonate is being bathed, or if necessary and acceptable to the client removed and replaced afterward.
When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next? A) Determine the length of the mother's labor. B) Notify the primary health care provider immediately. C) Keep the neonate under the radiant warmer for 2 hours. D) Obtain a blood sample to check for hypoglycemia.
B) Notify the primary health care provider immediately. Reason: Ortolani's 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's sign, suggesting a possible hip dislocation. The nurse should notify the primary health care provider promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. 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 primigravid client gives birth to a full-term girl. When teaching the client and her partner how to change their neonate's diaper, the nurse should instruct them to: A) fold a cloth diaper so that a double thickness covers the front. B) clean and dry the neonate's perineal area from front to back. C) place a disposable diaper over a cloth diaper to provide extra protection. D) position the neonate so that urine will fall to the back of the diaper.
B) clean and dry the neonate's perineal area from front to back. Reason: When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? A) Administer insulin subcutaneously. B) Administer a bolus of glucose I.V. C) Provide frequent early feedings with formula. D) Avoid oral feedings.
C) Provide frequent early feedings with formula. Reason: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.
A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should: A) Notify the primary care provider. B) Administer the ordered fluids. C) Verify that the infant has urinated. D) Have the potassium level redrawn.
C) Verify that the infant has urinated. Reason: Normal serum potassium levels are 3.5-4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4Meq/l is not unexpected and should be corrected with the ordered fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.
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: A) peripheral acrocyanosis. B) bradycardia. C) lethargy. D) jaundice.
C) lethargy. Reason: 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.
Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? A) An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old. B) An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old. C) An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old. D) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.
D) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old. Reason: Until the infant weighs 20 lb and is 1 year old, he should ride in a rear-facing car seat.
During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first? A) Start mouth-to-mouth resuscitation. B) Contact the neonatal resuscitation team. C) Raise the neonate's head and pat the back gently. D) Clear the neonate's airway with suction or gravity.
D) Clear the neonate's airway with suction or gravity. Reason: 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 his head or suctioning doesn't clear his 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.
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 primary health care provider is notified because the nurse suspects which of the following? A) Phimosis. B) Hydrocele. C) Epispadias. D) Hypospadias.
D) Hypospadias. Reason: 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 extrophy.