The Neonate

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?

"Antibodies are not usually formed until after exposure to an antigen."

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond?

"They're normal and will disappear as the baby's skin thickens."

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?

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis."

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.

For almost an hour after birth, a neonate was awake, alert, and startled and cried easily. Respirations rose to 70 breaths/minute, and heart rate on two occasions was 160 bpm. After sleeping quietly for about 2 hours, the neonate then awoke with a start, cried, extended, and flexed all four extremities, and then choked, gagged, and regurgitated some thick mucus. What should the nurse do next?

Change the neonate's position and aspirate mucus as necessary.

On examination of an African newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which of the following actions of the nurse is appropriate?

Consider the finding as normal in Africans.

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?

Deficient knowledge related to lack of exposure to apnea monitor.

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spot

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?

Notify the health care provider (HCP) immediately.

Assessment of a 2-day-old neonate born at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. What is the priority intervention?

Obtain a prescription for a stat chest x-ray.

A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized?

Participate in care of the twins as much as possible.

A viable neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:

Position the infant away from drafts and cooling ducts.

A neonate born at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75% on room air. What should the nurse do?

Provide supplemental oxygen.

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?

Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple.

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

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

A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition?

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?

hypoglycemia

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 nurse notifies the healthcare provider because the nurse suspects which disorder?

hypospadias

After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which factor?

immaturity of the central nervous system

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 appropriate

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information.

After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at birth, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which complication?

polycythemia

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?

pyloric stenosis

Discharge planning is being finalized for a neonate who was born at 32 weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents?

"An ophthalmologist will examine the baby before discharge."

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?

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

During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response?

"Formula is the food best digested by the baby until about 4 to 6 months of age."

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 nearly horizontally and take frequent breaks as the baby pauses between sucks."

The nurse is preparing to administer a vitamin K injection to a male neonate shortly after birth. What statement by the mother indicates that she understands the purpose of the injection?

"My baby does not have the normal bacteria in his intestines to produce this vitamin."

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. What should the nurse should tell the mother?

"Oxygen is drying to the mucous membranes unless it is humidified."

The nurse is discharging a newborn to home. Which discharge instructions will the nurse give to the newborn's parents? Select all that apply.

"Sponge bathe as needed until the umbilical cord comes off." "Ensure that feedings occur every 3 to 4 hours." "Place newborn in a rear-facing car seat.

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?

"We should weigh our baby daily to make sure he is gaining weight."

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching?

"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?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older."

The nurse is caring for a newborn that has been prescribed naloxone hydrochloride. The newborn weighs 2.5 kg. The order states to give 0.1 mg/kg now. How many milligrams will the nurse administer to the newborn? Record your answer using two decimal places.

0.25

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 a whole number.

240

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

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

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

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?

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

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

C

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.

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?

Continue feeding every 3 to 4 hours since the weight loss is normal.

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?

Demonstrate ways that the client can comfort her baby.

The nurse is a assessing a newborn and notes the presence of strabismus. Which is the nurse's best action?

Document the findings in the newborn's chart.

The nurse observes a darkish blue pigment on the buttocks and back of a neonate of African descent. Which action is most appropriate?

Document this observation in the child's medical record.

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.

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?

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?

Identify this reflex as a normal finding.

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?

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

When the nurse accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which reflex?

Moro reflex

The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first?

Mother: fundus is firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute.

A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus?

Neonates commonly lack eye muscle coordination.

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?

Notify the health care provider (HCP) immediately.

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Notify the primary care provider because this may indicate a neurologic problem.

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?

Place the infant skin to skin with the mother.

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.

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 foreskin is used to repair the deformity surgically.

The nurse notes that a neonate's Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate?

The neonate was in stable condition.

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. They will be able to visit and care for their baby

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do?

Use constant, gentle touch.

When developing the plan of care for a neonate, what measure should the nurse include to prevent heat loss from conduction?

Warm the stethoscope before using it.

A small-for-gestational-age infant is born with facial abnormalities and vision abnormalities. These abnormalities are likely caused by which maternal factor?

alcohol consumption

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:

a curdled appearance.

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?

a state of deep sleep

Which complication is common in neonates who receive prolonged mechanical ventilation at birth?

bronchopulmonary dysplasia

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

bulging fontanels

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

drug dependence.

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

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?

fine, downy hair over the upper arms and back

The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition?

good

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?

hypoglycemia

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?

hypoglycemia

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 signs and symptoms of which signs and symptoms should be a priority in this neonate?

hypoglycemia

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?

impaired gas exchange

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason?

interrupted supply of maternal glucose and continued high neonatal insulin production

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode?

jitteriness

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring

A registered nurse on the neonatal unit appropriately uses the chain of command when

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

A healthy neonate was just born in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss?

placing the infant skin-to-skin on the mother

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information?

presence of maternal antibodies

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief?

shock

A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from

the neonate's mother because she's considered an emancipated minor.

After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which agent?

warm water

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight

When assessing a postterm neonate, what is considered a normal finding?

wrinkled, peeling skin