Unit 2

What is the pathophysiology of bronchopulmonary dysplasia/BPD

Damage to infant's lungs -requires prolonged dependence on O2 Happens in infants under 32 weeks & in 1/3 of VLBW Due to a combination of factors that damage the airway Major sign is increased need for oxygen or inability to be weaned from respiratory support & O2 -tachycardia, tachypnea, retractions, crackles, wheezing, respiratory acidosis, cyanosis, increased secretions, bronchospasm, lung changes on chest X-ray

What are the different behavioral states of a newborn

Deep or quiet sleep state Light or active sleep state Drowsy state Quiet alert state Active alert state Crying state

What are specific S/S of intraventricular hemorrhage/IVH

Determined by severity of hemorrhage -subtle-remarkable Lethargy Poor muscle tone Bradycardia Deterioration of respiratory status -w/ cyanosis, apnea, Hct drop, acidosis, hyperglycemia, tense fontanel, & seizure Increased head circumference Preemies have increased risk

What are the 4 types of heat loss

Evaporation-wet linens/clothes, insensible water loss Conduction-cold surfaces (scale, circumcision board, hands, stethoscope) Convection-drafts, A.C., currents (people moving) Radiation-near cold surfaces (crib, incubator, walls, windows)

What causes preterm birth

Exact causes not known All risk factors in pregnancy are potential causes (Box 16.1 on pg. 438 has risk factors)

What does fetal lung fluid do

Expands alveoli Essential for normal lung development Some is emptied from lungs into amniotic fluid Continuously produced Is less produced as fetus nears term Starts to reabsorb during early labor During labor even more fluid is absorbed (may be delayed in c-section without labor) Needs to be cleared for newborn to breathe air

What does a stable newborn with no signs of respiratory distress look like? What do you expect to see/not to see? Normal vitals? Appearance?

Expect to see -good pink color -RR 30-60 -irregular respiratory pattern -regular vitals -HR 100-160 -acrocyanosis -normal appearance -flexed position Don't expect to see -grunting -nasal flaring -retractions -dusky color (face or centrally/torso) -lethargic -overly irritable/inconsolable

You are a newborn nurse preparing to administer the vitamin K injection to an infant born 30 min ago. The parents decline the med stating they believe "vaccines cause autism". What do you say to the parents?

Explain it's not a vaccine, it's properties, why it's needed Explain risks of not giving it Explain clinical studies unfound link of vaccines & autism (author retracted those results) Offer to discuss it further w/ Dr if they want A signed waiver is required for refusal

What is considered small for gestation age/SGA infants

Fall below 10th percentile in size on growth charts May be preterm, full term, or post term Many risk factors may predispose infant to be SGA -poor placental function -illness of mother (preeclampsia, severe diabetes) Full term SGA are at risk for many of same complications as preterm & post term infants

What other factor contributes to ↓ pulmonary vascular resistance?

Fetal lung fluid shifts into interstitial spaces & is removed by blood & lymph vessels

What is the importance of the first breath

Forces remaining lung fluid out of alveoli & allows air to enter lungs (first breath takes a lot more "work" to happen than subsequent breaths)

Filling of stomach stimulates what in newborn

Gastrocolic reflex (↑intestinal peristalsis) -tend to have a BM during/after feeding

What is the resulting pressure of collapsed, fluid-filled lungs & effects

HIGH pressure, therefore only a very small amount of blood can flow into the narrow vessels of the lungs

What is the difference between venous & heelstick samples

Heelstick blood samples show higher H&H & erythrocyte values than Venous blood samples

What is given to woman in preterm labor to ↑ surfactant production & speed maturation of lungs to ↓ RDS (most effective if given b/w 23-34 weeks)

IM steroids (Dexamethasone/Betamethasone)

How/What to assess all infants with hypoglycemia S/S

If below 45 mg/dL (follow agency protocol) Feed right away to prevent further glucose depletion May use oral glucose gel If severe, may need IV dextrose Repeat glucose screenings per agency policy

What is done for managing post term infants

If mom overdue, schedule placental functioning test If asphyxia/MAS, respiratory support at birth During labor & delivery, careful monitor 'decelerations' Respiratory resuscitation & ongoing management Assess for hypoglycemia r/t rapid glycogen stores depletion Monitor temp because fat stores used up for nourishment in utero

Which immunoglobulin is the only one that crosses the placenta (begins in 1st trimester but most occurs in 3rd trimester)

IgG (immunoglobulin G)

What are S/S of necrotizing enterocolitis/NEC

Increased abdominal girth Increased gastric residuals Decreased or absent bowel sounds Loops of bowel seen through abdominal wall -"sausage loops" Vomiting Bile-stained residuals or emesis Abdominal tenderness and discoloration Signs of infection Occult blood in stools On x-ray: presence of air within intestinal wall

What are common signs of pain in infants

Increased/decreased HR/RR, apnea Eyes squeezed shut Increased BP Mouth open Decreased O2 sat Grimacing Color changes (red, dusky, pale) Furrowing/bulging brow High pitched, intense, harsh cry Tense/rigid muscles or flaccid Whimpering, moaning Rigidity or flailing of extremities "Cry face" Sleep-wake pattern changes

What are some issues with respiratory preterm infants experiences

Infants born before adequate surfactant production (34 weeks) develop respiratory distress syndrome (RDS) Weak or absent cough reflex Narrow respiratory passages

What is the pathophysiology of retinopathy of prematurity/ROP

Injury to eye vessels leads to growth of new vessels that abnormally develop & may cause impairment/blindness Exact cause unknown -high O2 level in blood is risk factor Can be screened to detect changes in the eye Laser surgery to destroy abnormal vessels -current treatment of choice Nurse should ensure O2 is titrated -to keep saturation in prescribed limits

What is the pathophysiology of asphyxia/lack of O2

Insufficient O2 & excess CO2 in blood & tissues May occur in utero, at birth, or later -results in major organ ischemia (reduced blood flow) Maternal factors: hypertension, infection, drug use Placental factors: placenta previa, placental abruption, postmaturity Fetal factors: cord problems, infection, premature birth, multifetal gestation

What are effects on infant of a diabetic mother

Insulin acts as a growth hormone -results in macrosomia Strict control of the mother's blood glucose level -especially in 3rd trimester, reduces risk for macrosomia When Mom is hyperglycemic -large amounts of amino acids, free fatty acids, & glucose are transferred to the fetus Insulin doesn't cross placenta (molecules are too large) Excessive glucose received by fetus -causes fetal pancreas to secrete large amounts of insulin, & leads to hypertrophy of the islet cells This leads to hypoglycemia after birth -when mom's supply of glucose is cut off but infant's high insulin production continues If mom has long term diabetes (Type 1) with vascular changes -infant may actually have IUGR instead of macrosomia (decreased placental blood flow) Hypertension often occurs in women with diabetes -further compromises uteroplacental blood flow (causing IUGR)

What causes depletion of brown fat stores before birth

Intrauterine growth restriction (IUGR) may deplete brown fat stores before birth

What are S/S of intrauterine drug exposure

Irritability Jitters, tremors, seizures Increased muscle tone Restless, excessive activity Exaggerated Moro reflex Prolonged high-pitched cry Difficult to console Poor sleeping patterns Yawning Exaggerated rooting reflex Excessive sucking Uncoordinated suck/swallow Frequent regurgitation Diarrhea Weight loss Nasal stuffiness, sneezing Tachypnea, periods of apnea Retractions Tachycardia HTN Fever Sweating Excoriation of skin Mottling

How is pathologic/nonphysiologic jaundice treated

Is often Tx with phototherapy

How to restore thermoregulation if low temperature develops in previously normothermic infant

Look for obvious causes & fix Skin-to-skin, only diaper & hat on, warm blanket placed over If skin-to-skin not possible, add extra clothing Significant drop in temp drop or temp not coming up after 1 hr of skin-to-skin contact requires additional measures (radiant warmer with servo-control) Gradually ↑temp to normal (97.7-99.5°F [36.5-37.5°C])

What are preterm problems with fluid & electrolyte balances

Lose fluid very easily Rapid RR, use of O2, thin skin, radiant warmers, phototherapy lights Ability of kidneys to concentrate/dilute urine is poor Normal urinary output is 1-3 mL/kg/hr for first few days After 24 hours, output less than 0.5 mL/kg/hr Regulation of electrolytes by kidneys also a problem Need higher intake of Na, kidneys don't reabsorb it well (can't have too much, Na & H2O overload susceptible) Careful I&O

What is transient tachypnea of the newborn/TTN

More serious Rapid respiration's after birth -from inadequate absorption of fetal lung fluid -no surfactant Usually resolves quicker (within 24-48 hours) Causes respiratory distress Tachypnea develops within 6 hours of birth Grunting, retractions, nasal flaring, mild cyanosis Treatment is supportive -O2 for cyanosis -gavage feedings prevent aspiration & conserve energy Observed closely for RDS, sepsis (S/S are very similar) -antibiotics likely given until sepsis is ruled out

What is the most common cause of pathologic/nonphysiologic jaundice

Newborn hemolytic disease from incompatibility b/w mom's blood & fetus's blood

What is suspected if meconium is not passed by 48 hours

Obstruction

What helps prevent developing a flat head (positional plagiocephaly)

Place on abdomen several times/day when awake (tummy time) Need to be supervised at *ALL* times

When does physiologic/nonpathologic/developmental jaundice occur

*Appears after 24 hours, usually on day 2 or 3* Visible when bilirubin is > 5 mg/dL Bilirubin peaks b/w day 2-4 & falls to normal by day 5-7 Rate of rise/fall is important -determines if newborn values follow expected age & birth weight curve (serum bilirubin nomogram)

What are S/S of respiratory distress

*Tachypnea* *Retractions* *Nare flaring* *Cyanosis* *Grunting* *Seesaw/Paradoxical respiration's* (chest falls, abdomen rises & chest rises, abdomen falls) *Asymmetry or ↓ movement on 1 side of chest * (during expansion) *Choanal Atresia * (nasal passage(s) block/narrowing from bone/tissue) *Abnormal skin color * (palor/ruddiness [red]) *Abnormal heart sounds * (tachycardia/bradycardia, irreg rhythm, murmur) *Abnormal heart position* *Abnormal brachial & femoral pulses * (unequal bilaterally, rates/strengths are different) *Hypotension, Equal BP x4 Extremities* *Abnormal capillary refill* (≥ 5 seconds)

A nurse is caring for a preterm infant with necrotizing enterocolitis (NEC). Which nursing intervention is most important for this infant? 1 Measuring abdominal girth frequently 2 Diluting the formula mixture as prescribed 3 Administering oxygen before the gastric feeding 4 Using half-strength formula for gavage feeding

1 Measuring abdominal girth frequently

An infant born at 36 weeks' gestation weighs 4 lbs 3 oz (1,899 g) and has Apgar scores of 7 and 9. Which nursing actions will be performed upon the infant's admission to the nursery? *Select all that apply* 1 Recording the neonate's vital signs 2 Administration nasal cannula oxygen 3 Offering a bottle of dextrose in water 4 Evaluation of the neonate's health status 5 Keeping the neonate's body warm

1 Recording the neonate's vital signs 4 Evaluation of the neonate's health status 5 Keeping the neonate's body warm

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider? 1 Weight of 6 lb 4 oz (2835 g) 2 Hemoglobin of 16.2 g/dL (162 mmol/L) 3 Three wet diapers over the last 12 hours 4 Total serum bilirubin of 10 mg/dL (171 µmol/L)

1 Weight of 6 lb 4 oz (2835 g)

Newborn's reaction to heat loss

1.) Newborns become restless & cry instead of shivering (except during prolonged exposure to cold) -this ↑ activity & flexion helps generate warmth & reduce heat loss from exposed surface areas -cold exposure=also causes peripheral vasoconstriction (↓blood flow-skin [prevents heat loss from the skin]) -when newborn temp drops, metabolic rate ↑ 200-300% (causes excessive O₂ & glucose use) 2.) Non-shivering thermogenesis

What is the range of extremely low birth weight

1000 g or less

What is normal newborn hemoglobin levels

15-24 g/dL (higher than adults)

What is the range of very low birth weight

1500 g or less

What does IgM (immunoglobulin M) do

1st Ig produced by body when newborn is challenged -helps protect against gram-negative bacteria -rapidly produced a few days after birth (due to exposure to environment) If in cord blood=exposure to infection in utero occurred

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of what characteristic of the scalp edema in caput succedaneum? 1 Becomes ecchymotic 2 Crosses the suture line 3 Increases after several hours 4 Is tender in the surrounding area

2 Crosses the suture line

A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem should the nurse anticipate when planning care for this infant? 1 Anemia 2 Hypoglycemia 3 Protein deficiency 4 Calcium deficiency

2 Hypoglycemia

What amount of air from first breaths stays in lungs to become the functional residual capacity (FRC)

20-30 mL

What is the range of low birth weight

2500 g or less at birth

A newborn of 30 weeks' gestation has a heart rate of 86 beats/min & slow, irregular respiration's. The infant grimaces in response to suctioning, is cyanotic, & has flaccid muscle tone. What Apgar score should nurse assign to the neonate? Answer with a whole number.

3 (HR<100=1; slow/irregular respiration's=1; grimaces response to suctioning=1; flaccid muscle tone=0 points; & cyanosis=0, Total=APGAR score of *3*)

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant? 1 Less than 40% 2 More than 75% 3 Between 45% and 65% 4 Between 65% and 75%

3 Between 45% and 65%

Five minutes after birth, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? 1 Cerebral palsy 2 Neonatal syphilis 3 Opioid drug withdrawal 4 Fetal alcohol syndrome

3 Opioid drug withdrawal

What carries a lot of blood away from lungs (some away from liver) in a fetus still in utero

3 shunts -ductus venosus -foramen ovale -ductus arteriosus

What is the age range of late preterm infants

34 weeks & 0 days - 36 weeks & 6 days Born before 37 completed weeks of gestation

What does an Apgar score recorded 5 minutes after birth assist the nurse in evaluating when caring for the newborn? 1 Gestational age of the newborn 2 Effectiveness of the birthing process 3 Possibility of respiratory distress syndrome 4 Adequacy of the transition to extrauterine life

4 Adequacy of the transition to extrauterine life

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points? 1 Color: pale 2 Respiratory rate: slow 3 Reflex irritability: grimace 4 Heart rate: 100 beats/min

4 Heart rate: 100 beats/min

What is normal newborn RBC levels

4.8-7.1 million/mcL (higher than adults)

What is normal newborn hematocrit levels

44-70% 65%+ from central site = polycythemia (↑RBC) -viscous, thick blood -↑risk for jaundice; injury to brain & organs due to stasis -respiratory distress & hypoglycemia are more common -occurs when poor O2 in utero causes fetus to try to compensate by producing more RBC's than normal -more common in post term, LGA, SGA, or IUGR infants -also maternal smoking, HTN, diabetes -delayed cord clamp, twin-twin transfusion are also causes

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Answer with a whole number.

8 -1 point lessened muscle tone/baby's arms don't flex -1 point for acrocyanosis (10-1-1=*8*)

What are transitional stools

A combination of meconium & milk stools

What do infants develop as result of spending too much time in supine position

A flat head (positional plagiocephaly)

What is the American Academy of Pediatrics (AAP) view on circumcision

AAP recently stated that health benefits outweigh the risks, but benefits are not so great that it should be recommended as a routine for all newborns

What is erythroblastosis fetalis

Agglutination & hemolysis of fetal erythrocytes -from maternal-fetal blood incompatibility

Route of taking temperature & what is the normal range

Axillary temperature Normal range 97.7-99.5°F (36.5-37.5°C)

What further assessments would you consider doing on a newborn having difficulty maintaining a normal temp?

Blood glucose test Color/Cap Refill O2 saturation Overall muscle tone/neuro status (lethargic) S/S of respiratory distress How have they been feeding

What is the pathophysiology of short bowel syndrome/SBS

Bowel that is shorter than normal Caused by congenital malformations of GI tract or surgical resection that decreases length of intestines When bowel too short, decreased mucosal surface area causes inadequate absorption of fluids, electrolytes, & nutrients Most common symptoms are malabsorption, diarrhea, & failure to thrive TPN will be primary source of nutrition Enteral nutrition begun asap; assess for tolerance

What is periodic breathing

Breathing cessation for 5-10 seconds w/o other changes followed by 10-15 seconds of rapid breathing

What are risk factors of transient tachypnea of the newborn/TTN

C-section (with or without labor) Macrosomia Multiples Excessive maternal sedation Prolonged or precipitous labor Male gender Maternal diabetes or asthma

What initiates breathing

Chemical/Mechanical/Thermal/Sensory factors that -Stimulate the respiratory center in medulla of brain -Trigger respiration's

What are complications of circumcision

Complications are rare Hemorrhage & Infection Removal of too much or too little of prepuce Unsatisfactory cosmetic result Urinary retention Stenosis or fistulas of urethra Adhesion's, necrosis, or other injury may occur

What are benefits of circumcision

Reduces penile cancer Reduces UTI's in first year of life Reduces HIV infection Reduces transmission of other STI's

Where is IgA (immunoglobulin A) found

Secretory IgA present in colostrum & breast milk -breastfed infants may get protection that formula fed infants do not

What is surfactant

Slippery, detergent-like combination of lipoproteins that lines the inside of alveoli & is detectable by 24-25 weeks gestation

What can happen if newborn is not kept warm at birth

Temperature may drop as much as 0.5-1.7°F/min

Whay are absence of kidneys or anomalies that interfere with urination usually discovered before birth

They cause *oligohydramnios* & would've been *investigated by ultrasound*

Why is eye ointment given immediately following birth

To prevent ophthalmia neonatorum (conjunctivitis caused by Neisseria gonorrhoeae) - 0.5% erythromycin/1% tetracycline ophthalmic ointment given within 1-2 hr of birth

When checking total serum bilirubin (TSB) what is tested

Unconjugated & Conjugated serum bilirubin (Indirect & Direct serum bilirubin)

What are some ongoing assessments & care

Weighed once a day per policy Document & track weight loss or weight gain 5-10% weight loss expected during hospital stay Turgor checked over chest or abdomen (no tenting) Bathing done when temp is stable Removal of all vernix is unnecessary (very moisturizing, good for skin) 1st clean area if lab draw/puncture needed before bath (still consider not clean, prevent infection) Can be immersed in tub (better for temp maintenance) Water approximately 100°F to less than 104°F Giving a sponge bath is done under radiant warmer Baths done quickly; dry thoroughly; stay under warmer til temp is stable; recheck temp in 1 hr Bath in presence of parents (point out newborn characteristics & how to bathe)

Which infant is at greater risk to develop cold stress? a. Full-term infant delivered vaginally without complications b. 36-week infant with an APGAR score of 7 to 9 c. 38-week infant c-section delivery r/t cephalopelvic disproportion d. Term infant delivered vaginally with epidural anesthesia

b. 36-week infant with an APGAR score of 7 to 9

The nurse is explaining how a newly delivered baby initiates respiration's. Which statement explains this process? a. Drying off the infant b. Chemical, thermal, and mechanical factors c. An increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale

b. Chemical, thermal, and mechanical factors

Which organs are nonfunctional during fetal life? a. Eyes and ears b. Lungs and liver c. Kidneys and adrenals d. Gastrointestinal system

b. Lungs and liver

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is: a. Soft and supple skin. b. A hematocrit level of 55%. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

c. Lack of subcutaneous fat.

In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n): a. Hematocrit level of 58%. b. RBC count of 5 million/mL. c. WBC count of 15,000 cells/mm3. d. Blood glucose level of 25 mg/dL.

d. Blood glucose level of 25 mg/dL.

In comparison with the term infant, the preterm infant has: a. More subcutaneous fat. b. Well-developed flexor muscles. c. Few blood vessels visible through the skin. d. Greater surface area in proportion to weight.

d. Greater surface area in proportion to weight.

Which is the purpose of state-required newborn screening? a. Keep the state records updated. b. Document the number of births. c. Allow for accurate statistical information. d. Recognize and treat newborn disorders early.

d. Recognize and treat newborn disorders early.

What are functions of the liver after birth

*Blood glucose maintenance* -falls to lowest level 60-90 min after birth -stabilizes after 2-3 hours -normal newborn glucose level = 40-60 mg/dL on day 1 & 50-90 mg/dL after that glucose level below 45 mg/dL indicates hypoglycemia *Conjugation of bilirubin* -liver changes unconjugated/indirect bilirubin that that is soluble in fat but not in water (can't be excreted) into a water-soluble form (can be excreted) -unconjugated/toxic bilirubin is fat soluble (can be absorbed by subcutaneous fat) causing jaundice -excess build up in blood may cause staining of brain tissues, acute bilirubin encephalopathy, & can progress to permanent neurologic injury (kernicterus) *Blood coagulation* -prothrombin & clotting factors produced in liver (activated by vit. K) *Iron storage* -stored in liver & spleen in last weeks of pregnancy -breastfeeding: don't need supplement until 6 months -formula feeding: needs to be an iron-fortified formula *Metabolism of drugs* -inefficient metabolism of drugs

What is the importance of newborns having a ↓ tolerance for changes in total body fluid vol. than older infants

*Carefully monitor I&O* -IV rate, measure output, monitor S/S, mindful maintenance of fluid balance (full term infants need 60-100 mL/kg during first 3-5 days & 150-175 mL/kg/day by 1 week) Infants have higher fluid to size ratio than adults -large portion of it is located outside the cells (total body water is easily depleted)

When does pathologic/nonphysiologic jaundice occur

*I the first 24 hours* (main difference) -Bilirubin rises higher or more rapidly than expected or stays elevated longer than expected (Tx is needed) -Result of abnormalities cause excessive RBC destruction or bilirubin conjugation problems -Incompatibilities b/w mother & infant blood types, infection, metabolic disorders

What are the hazards of cold stress

*↑O₂ need * -↑metabolic rate & ↑brown fat metabolism=↑O₂ need (they are using it up) -if they already have even mild respiratory distress, the problem worsens if more O₂ is used for heat production *↓surfactant production* -↓lung expansion & furthers respiratory distress *Respiratory distress* -↓lung expansion & furthers respiratory distress -peripheral vessels vasoconstrict (reduce skin heat loss) -↓O₂ blood concentration may cause vasoconstriction of pulmonary vessels (worsening respiratory distress) *Hypoglycemia* -↑metabolic rate to produce heat (uses up a lot of glucose) -glycogen stores converted to glucose (can quickly deplete & lead to hypoglycemia) *Metabolic acidosis* -glucose metabolism when there's not enough O₂ available causes ↑production of acids -brown fat metabolism also releases fatty acids (can result in metabolic acidosis) *Jaundice* -↑fatty acids in blood can interfere with transport of bilirubin to the liver (↑risk of jaundice)

What chemical factors are involved with respiration's

*↓PO2/↓pH/↑PCO2* ↓ in partial pressure of oxygen (PO₂) ↓ in pH ↑ in partial pressure of carbon dioxide (PCO₂) in blood (affects chemoreceptors in carotid arteries & aorta which stimulates respiratory center in medulla)

What mechanical factors are involved with respiration's

-Fetal chest compressed/squeezed during vag birth (forces fetal lung fluid out of lungs into upper air passages, fluid passes out of mouth/nose as head emerges *bulb suction of mouth & then nose to help remove fluid*, M [mouth] before N [nose]) -Pressure of chest is released at birth (recoil helps draw air into lungs & remove airway fluid) C-section babies don't get squeeze resulting in wet crackly lung sounds

What is the state of the intestines of the newborn

-Long in proportion to newborn size & compared with those of adult -Added length allows more surface area for absorption but makes infants more prone to water loss with diarrhea -can hear bowel sounds 15 min after birth -digestive tract is sterile at birth (normal intestinal flora established within first few days)

What to look for in late preterm infants

-Many needs similar to preterms -Often look full-term but are physiologically immature -Risk for respiratory disorders -Problems with temp maintenance,hypoglycemia, hyperbilirubinemia, feeding difficulties, acidosis, & infection due to immaturity -More likely to be admitted to NICU after birth -At ↑ risk for hospitalization after discharge

Newborn response to hyperthermia

-↑temp=↑metabolic rate causes ↑O₂ & glucose needs (possible metabolic acidosis) -Peripheral vasodilation leads to ↑fluid losses -Can sweat but is often delayed (because sweat glands are immature) -Overheated [poorly regulated/monitored equipment] (radiant warmers, warmed incubators)

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? *Select all that apply* 1 "Wash your hands before touching the newborn." 2 "Send the newborn to nursery to be monitored during the night." 3 "All client identification bands should remain in place until discharge." 4 "Do not let anyone remove the infant from your sight while you are in the hospital." 5 "Check the identification of staff, and if there is a question of validity, call the nursing station."

1 "Wash your hands before touching the newborn." 3 "All client identification bands should remain in place until discharge." 5 "Check the identification of staff, and if there is a question of validity, call the nursing station."

The nurse in the birthing room is assessing a newborn. Which characteristic would be assigned an Apgar value of 2? 1 A strong cry 2 A heart rate of 90 beats/min 3 Slight flexion of legs and arms 4 Pink body and blue extremities

1 A strong cry

A primipara has just given birth at 37 weeks' gestation. What should the nurse do to assist the attachment process between the mother and her newborn? 1 Encourage continuous rooming-in 2 Assign one nurse to care for both of them 3 Allow extra visiting privileges in the nursery 4 Teach the client how to breast-feed the baby

1 Encourage continuous rooming-in

What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? 1 Encouraging more frequent breastfeeding during the first 2 days 2 Instituting phototherapy for 30 minutes every 6 hours for 3 days 3 Substituting formula feeding for breastfeeding on the second day 4 Supplementing breastfeeding with glucose water during first day

1 Encouraging more frequent breastfeeding during the first 2 days

A preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents? 1 Fear of handling the infant 2 Delayed ability to bond with the infant 3 Prolonged hospital stay needed by the infant 4 Inability to provide breast milk for the infant

1 Fear of handling the infant

The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? *Select all that apply* 1 Pallor 2 Irritability 3 Hypotonia 4 Ineffective sucking 5 Excessive birth weight

1 Pallor 2 Irritability 3 Hypotonia 4 Ineffective sucking

A nurse is planning to teach the parents of a preterm infant regarding the infant's nutritional needs. Some nutrients are required in greater quantities in a preterm infant than a full-term one. Which nutrients should the nurse include in the plan? 1 Proteins 2 Carbohydrates 3 Vitamins A, D, E, and K 4 Calcium and phosphorus

1 Proteins

The nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? *Select all that apply* 1 Sneezing 2 Hyperactivity 3 High-pitched cry 4 Exaggerated Moro reflex 5 Reduced deep tendon reflexes

1 Sneezing 2 Hyperactivity 3 High-pitched cry 4 Exaggerated Moro reflex

The nurse is caring for a newborn with a caput succedaneum. What is the priority nursing action? 1 Supporting the parents 2 Recording neurologic signs 3 Applying a hard protective cap on the head 4 Applying ice packs to the hematoma

1 Supporting the parents

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1 The rib cage is not compressed and released during birth. 2 The sudden temperature change at birth causes aspiration. 3 There is usually oxygen deprivation after a cesarean birth. 4 There is no gravity during birth to promote drainage from the lungs.

1 The rib cage is not compressed and released during birth.

An infant born in a birthing center is being transferred to a regional neonatal intensive care unit because of respiratory distress. Which nursing action best promotes parent-infant attachment? 1 Encouraging the parents to call their infant by name 2 Allowing the parents to hold their infant before departure 3 Giving the parents a picture of their infant in the intensive care unit 4 Instructing parents to contact the neonatal intensive care unit daily

2 Allowing the parents to hold their infant before departure

A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respiration's. With which condition are these signs associated? 1 Hypervolemia 2 Hypoglycemia 3 Hypercalcemia 4 Hypothyroidism

2 Hypoglycemia

A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? 1 Testing the infant's stools for occult blood 2 Monitoring the infant's blood glucose level 3 Placing the infant in the Trendelenburg position 4 Comparing infant's head circumference and chest circumference

2 Monitoring the infant's blood glucose level

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy? 1 Covering the trunk to prevent hypothermia 2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turn after each feeding to reduce exposure of each surface area

2 Using shields on the eyes to protect them from the light

A nurse is teaching a prenatal class regarding infant safety. After the class several of the students are heard discussing what they have learned. The nurse determines that the teaching has been effective when one of the future parents makes which statement? 1 "My mother has already made the cutest pillowcases for the baby's pillows." 2 "I just bought a new baby seat that can be strapped into the front seat of the car." 3 "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." 4 "At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."

3 "My mother can't believe that babies are supposed to sleep on their backs, not their stomachs."

A client expresses a desire to breastfeed her preterm infant, who is being cared for in the neonatal intensive care unit. How should the nurse respond to this client's request? 1 By telling the client that this is not possible because the infant will be fed by means of gavage 2 By discouraging the client because of the time and effort it will take to pump her breasts 3 By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion 4 By explaining to the client that breast milk is inadequate for a preterm infant because it does not contain all the necessary nutrients

3 By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge? 1 To space feedings at every 3 hours 2 How to assess the fontanels for tenseness 3 How to monitor their child for signs of jaundice 4 To record the number of wet diapers during the first 24 hours

3 How to monitor their child for signs of jaundice

A newborn is admitted to the nursery. The newborn weighs 10 lb, 2 oz (4592 g), which is 2 lb (907 g) more than the birth weight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight? 1 Document the findings 2 Delay starting oral feedings 3 Perform serial glucose readings 4 Place the newborn in a heated crib

3 Perform serial glucose readings

The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother is by performing a heel stick blood test on the newborn. What specifically does this test determine? 1 Blood acidity 2 Glucose tolerance 3 Serum glucose level 4 Glycosylated hemoglobin level

3 Serum glucose level

At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation? 1 Stimulate crying 2 Substitute sterile water for the formula 3 Suction and then oxygenate the newborn 4 Stop the feeding momentarily and then restart it

3 Suction and then oxygenate the newborn

A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How should the nurse best respond? 1 "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2 "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3 "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4 "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

4 "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? 1 "It will keep your baby from going blind." 2 "This ointment will protect your baby from bright lights." 3 "There is a law that newborns must be given this medicine." 4 "This antibiotic helps keep babies from contracting eye infections."

4 "This antibiotic helps keep babies from contracting eye infections."

Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0 °F (36.7 °C) and 97.4 °F (36.3 °C) would be considered critical? 1 Respiratory rate of 60 breaths/min 2 White blood count greater than 15,000 mm3 3 Serum calcium level of 8 mg/dL (2 mmol/L) 4 Blood glucose level of 26 mg/dL (1.4 mmol/L)

4 Blood glucose level of 26 mg/dL (1.4 mmol/L)

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. Which test result should the nurse anticipate for this infant? 1 Increased Po2 2 Lowered HCO3 3 Decreased Pco2 4 Decreased blood pH

4 Decreased blood pH

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. How should the nurse explain the purpose of PKU testing to this mother? 1 It detects thyroid deficiency 2 It reveals possible brain damage 3 It identifies chromosomal damage 4 It is used to measure protein metabolism

4 It is used to measure protein metabolism

What is the optimal area for the nurse to assess adequate tissue oxygenation in a neonate born of African-American parents? 1 Heels and buttocks 2 Upper tips of the ears 3 Nailbeds on the hands and feet 4 Mucous membranes of the mouth

4 Mucous membranes of the mouth

The nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do to prevent retinopathy of prematurity (ROP)? 1 Cover the neonate's eyes with a shield 2 Place the neonate in an elevated side-lying position 3 Assess the neonate every hour with a pulse oximeter 4 Support the neonate's oxygen saturation while providing minimal FiO2

4 Support the neonate's oxygen saturation while providing minimal FiO2

How should the nurse screen the newborn of a diabetic mother for hypoglycemia? 1 Testing for glucose tolerance 2 Drawing blood for a serum glucose determination 3 Arranging for a fasting blood glucose determination 4 Testing heel blood with the use of a glucose-oxidase strip

4 Testing heel blood with the use of a glucose-oxidase strip

What is the normal blood volume & factors that causing variances

80-100 mL/kg Cord clamping timing, gestational age, newborn position when cord's clamped

What is normal newborn platelet levels

84,000-478,000/mm³ (similar to adults after 1st week)

What is normal newborn WBC levels

9100-34,000 /mm³ (average = 15,000/mm³) -↑WBC count doesn't necessarily mean infection (in fact it may ↓ with infection). ↑ immature leukocytes or ↓ platelets can = infection

What are early cares for newborn's

APGAR's at 1 & 5 minutes Stabilization as necessary (dry, stim., suction, etc.) Prophylactic med's given (vit. K & eye ointment) Temp, HR, RR/effort, color, muscle tone, LOC, & activity (ongoing assessments) Document every 30 min until newborn's stable for 2 hr *wear gloves during ALL contact until bath is given*

What is considered large for gestation age/LGA infants

Above the 90th percentile on growth charts "Macrosomic" (weight more than 4000 to 4500 g) Usually born at term, may be preterm or post term Often born to multiparas, large parents, certain ethnic groups, diabetic mothers, erythroblastosis fetalis More likely to have longer labor, injury during birth, or c-section due to failure to descend Shoulder dystocia -shoulders too large to fit through the pelvis Also skull or clavicle Fx, brachial plexus injury, cephalohematomas, bruising Management based on ID of suspected large infants -by measurement of fundal height & ultrasound Vacuum, forceps, c-section more likely Carefully assess for injuries & complications & Tx as arise

What are apneic spells

Absence of breathing for more than 20 sec, or less if also has cyanosis, pallor, bradycardia, or hypotonia -common in preterms -if no cause besides prematurity="apnea of prematurity" -gradually improves as infant matures -gentle stimulation, bag & mask ventilation, med's, or assisted ventilation

When does second period of reactivity occur & what occurs

After a quiet or sleepy period Lasts 4-6 hours Interested in feeding; may pass meconium May be tachycardia & rapid respiration's Mucus secretions ↑ May gag/regurgitate

What is checked during respiratory assessment's

Airway RR q 30 min& after stable for 2 hr (40-50/min) Respiratory effort Breath sounds Chest observation/auscultation/palpation

What does surfactant do

Allows alveoli to stay partially open (when newborn begins to breathe at birth) Prevents the alveoli from collapsing when infant exhales Collapse ↑ work of breathing & possibly atelectasis By 34-36 weeks there is usually enough to prevent RDS (birth before 34-36 weeks = ↑ risk of RDS)

How can you ensure newborn always goes to correct parents

Always check the ID bands

What describes the appearance of small for gestation age/SGA infants

Appearance varies -depends if growth restriction cause began early or late in pregnancy -affects weight first, then length & head size Symmetric growth restriction: involves entire body -small body, proportional, appears normally developed Asymmetric growth restriction: head is normal in size -appears large for body -length is normal -weight is small -abdominal C. is decreased (liver, spleen, & adrenals smaller than normal) -caused by complications started in 3rd trimester -interferes with uteroplacental function (ex. Preeclampsia)

How/Why is bilirubin assessed

Assessed by blanching skin on nose or sternum (turns white/pale before return to normal color after gently pressing on skin) Jaundice progresses head to toe Follow agency protocols (for transcutaneous or serum bilirubin measurements) Explain jaundice to parents (causes, significance, Tx)

What are the S/S of inadequate preterm thermoregulation

Axillary temperature < 36.3º C or > 36.9º C Skin temperature < 36º C or > 36.5º C Poor feeding or feeding intolerance Irritability followed by lethargy Weak cry or suck Decreased muscle tone Cool skin temperature Mottled, pale, acrocyanotic skin Signs of hypoglycemia Signs of respiratory difficulty Poor weight gain (if chronic)

What are some reminders of positioning a newborn for sleeping

Back to sleep [prevent SIDS] Firm surface No crib bumpers Avoid loose & soft bedding Use swaddlers & sack-like sleepers Do not share bed or couch with infant Recommended that they share a room Pacifier use [prevent SIDS] (delay w/breastfeeding til milk supply's well established)

What are preterm problems with infection

Be alert for signs of sepsis at all times Hand washing hugely important, limiting of visitors, etc Much higher incidence of infection Exposure to maternal infection, lack of adequate passive immunity from IgG transfer from Mom during third trimester, immature response to infection, prolonged stay in hospital, invasive procedures

What are S/S of respiratory distress syndrome/RDS

Begin during first hours after birth Tachypnea/Tachycardia Nasal flaring Cyanosis Retractions Grunting on expiration Decreased breath sounds/crackles Increased CO₂ & decreased O2 levels Chest x-ray: "ground glass" appearance

When does first period of reactivity occur & what occurs

Birth to about 30 minutes Active, wide awake, alert, interested in surroundings Movement, rooting, appear hungry Many latch & suck well for 1st breastfeeding May have lower temp, high RR, & high HR May have grunting, retractions, nasal flaring, crackle LS's

What is the pathophysiology of intraventricular hemorrhage/IVH

Bleeding into & around ventricles due to ruptured vessels Associated with increased/decreased BP, asphyxia, or RDS needing mechanical ventilation, increased or fluctuating cerebral blood flow Graded 1-4 according to amount of bleeding Signs vary & are determined by severity -could be subtle or significant Lethargy, poor muscle tone, bradycardia, deterioration of respiratory status, drop in Hct, acidosis, hyperglycemia, tense fontanel, seizures Usually diagnosed by ultrasound Nurses need to limit situations that increase IVH risk Measure head C., look for neurologic status changes

What could be a result of low levels of O₂ in the blood?

Blood vessels don't open, they close Shunts don't close, they open, & resistance ↑ Requires vitals q 30 min/first 2 hr If stable, vitals q 4 hr/during stay Ductus arteriosus dilate/open Pulmonary vessels constrict (↑ resistance to blood flow in lungs) Foramen ovale opens -allow a R-L shunt of blood (pulmonary artery-ductus arteriosus-aorta) PDA (patent ductus arteriosus) can occur if newborn experiences asphyxia, becomes hypoxic, or is preterm

What are post term infants

Born after 42nd week of gestation Placental function decreases w/ prolonged pregnancy If placental insufficiency present -oligohydramnios & compression of umbilical cord may occur -leads to fetus not getting enough O2 & nutrients -leads to hypoxia & malnourishment -leads to postmaturity syndrome When labor starts, poor O2 reserves cause fetal comp. -often pass meconium as result of low O2 before or during labor (increased risk of meconium aspiration)

When does brown fat develop

Brown fat accumulated mostly in 3rd trimester -preemies may be born before having adequate stores

What should parents be taught about circumcision

Call if more than a few blood drops in diaper on 1st day Call if any bleeding after 1st day Apply petroleum jelly q diaper change/first 4-7 days Squeeze warm water over penis & gently pat dry Expect yellow crust or scab to form, don't remove it Watch for S/S of infection Should be fully healed in approx. 10 days

What is the state of the cardiac sphincter & related effects

Cardiac sphincter located b/w esophagus & stomach -is relaxed (tend to regurgitate feedings easily/spit up

How can you preventing infant falls (drops)

Careful handling Parents can't hold baby for transport or in hall (must be in bassinet at all times for transport) Look at basic room safety Ensure C-section mom calls for help to get baby

What precautions can be taken to prevent newborn abductions

Careful identification Monitor suspicious visitors Question people that don't seem to have purpose (reason to be there) Being a "locked unit"

You are a postpartum nurse taking care of first-time parents & their baby boy, born 12 hr ago. They call you in the room in a panic, exclaiming that he "suddenly started choking & gagging". "It looks like he wasn't breathing!" the dad exclaims. The infant spit up a small amount of clear mucousy fluid. How do you react? What should you say/teach? Next action?

Check airway (patent) Show how to gently turn infant to side Show how to suction w/ bulb syringe Explain stimulating baby by rubbing feet or back -ensure good cry out afterwards (to ensure breathing) Validate fear & concern of being a scary incident Ed. bring-up excess amniotic fluid swallowed in delivery -common in first 24 hours or so (very normal) Have them do return demonstration of bulb syringe -reassure they did the right thing (use call light in that situation and whenever needed) Teach what normal breathing looks like Teach when to call you for help

How do you provide cord care

Check for bleeding/oozing during early hours Purulent drainage/redness/edema at base = infection Becomes brownish-black within 2-3 days Falls off within 10-14 days Clean cord with water & keep clean & dry Diaper folded below (to keep dry/prevent contamination by urine) Cord clamp removed after 24 hr (no bleeding danger if end is dry & crisp)

What are internal causes of the respiration

Chemical changes that take place at birth -↓PO₂, ↓pH, & ↑PCO₂ affect chemoreceptors in carotid arteries & aorta -message transmitted to respiratory center in medulla -diaphragm is stimulated to contract -newborn draws first breath

What are retractions

Chest skin sucked in -particularly noticeable due to weak chest wall

What is atelectasis

Collapse of all of a lung, or an area of a lung

How often are ongoing assessments & care done

Complete assessment q 4-8 hr/stay, per facility policy

What are nursing interventions for pain

Containment Kangaroo care and breastfeeding Minimize handling before a painful procedure Least traumatic activities first, then more painful Sucrose on pacifiers (use with caution) Talking softly, holding, rocking, swaddling

What are the treatments for pain r/t circumcision

Dorsal penile nerve block [lidocaine injection] (effective to eliminate pain during) Acetaminophen (given afterwards) Pacifiers, oral sucrose, swaddling, touch, talking softly Evaluate pain using NIPS pain scale

What sensory factors are involved with respiration's

Drying Stimulating Skin-to-skin Light Sounds Smells Pain

Why are newborns at risk for clotting deficiency during first days of life

Due to low levels of vitamin K -needed to activate several clotting factors (factors II [prothrombin], VII, IX, and X)

What keeps alveoli partially open so subsequent breaths require less effort than first one

FRC (functional residual capacity) & Surfactant

What are preterm problems with skin

Fragile, permeable, easily damaged skin Use of medical adhesives rather than tape if possible Moisten skin when removing Positioning, equipment puts pressure on skin (need careful assessment)

What describes the appearance of preterm infants

Frail, weak Less developed flexor muscles and muscle tone Limp extremities (little/no resistance when moved) Lie in extended position Head is large compared to rest of body Skin appears red/translucent w/ vessels clearly visible Nipples and areola hard to visualize May be covered in vernix and lanugo No plantar creases if under 32 weeks Pinnae flat, soft, & contain little cartilage (not rolled over)

What is the pathway of the umbilical vein

From placenta to liver & ductus venosus

What is the pathway of the ductus arteriosus

From pulmonary artery to aorta

What is the pathway of the foramen ovale

From right atrium to left atrium

What is the pathway of the ductus venosus

From umbilical vein to inferior vena cava

What is the impact of immature kidney function in newborns

GFR doesn't reach adult levels until 1-2 years -↓ ability to remove waste products from blood -may have small amount of glucose/amino acids in urine first few days -uric acid crystals may give urine a reddish color

What is phenylketonuria/PKU

Genetic disorder, causes CNS injury -from toxic levels of amino acid phenylalanine/Phe in the blood 1 in 10,000 children Result in severe cognitive impairment if left untreated All newborns screened for this before discharge from hospital or shortly after From liver enzyme deficiency, phenylalanine hydrolase -changes phenylalanine into tyrosine to be used Autosomal recessive disorder

You walk into your postpartum mom's room & she is sleeping heavily sitting up in her bed. She is cradling the baby in one arm, swaddled in a blanket. What do you do?

Gently & carefully take infant & place in bassinet Wake mom gently & explain safety -baby in crib while mom sleeps Let mom go back to sleep When mom awakes return for thorough/clear teaching -unsafe to sleep w/ baby in bed [fall/suffocation risk] (wait until awake to ensure she can process teaching)

What thermal factors are involved with respiration's

Go from warm, fluid-filled uterus to a cold room (sensors in skin respond to change & send impulses to respiratory center in medulla)`

What is the normal voiding pattern of newborn's

Half void within 12 hours 99% by 48 hours 6 voids/day by day 4 No void: likely r/t low fluid vol. from inadequate intake

How can you prevent infections or recognize early S/S

Hand hygiene Teach everyone hand hygiene Teach to not kiss baby Early S/S of infection -low temp -poor feeding -lethargic -neuro status change -hyperglycemia -poor color -look mottled -periods of apnea without obvious cause -unexplained changes in behavior -obvious signs of infection (eyes, cord, circumcision site)

What are preterm problems with thermoregulation

Heat loss more rapid than full-term -thinner skin, blood vessels near surface, less white fat, less brown fat accumulated before birth, larger head, extended extremities, temp control center is less mature Complications from heat loss more likely to develop -hypoglycemia, respiratory problems, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production -calories used for heat production are unavailable for growth & weight gain Remain in incubator/isolette, -until they are ready to wean to open crib (weigh 1600 g, consistent weight gain for several days, no complications, tolerating feedings)

Bruising, Cephalhematoma, Normal RBC break down, Rh/ABO incompatibilities lead to what

Hemolysis of RBC's

What are factors in ↑ bilirubin/hyperbilirubinemia

Hemolysis of excessive erythrocytes Excess bilirubin production Short RBC life span Liver immaturity ↓albumin, ↓albumin-binding capacity, & ↓albumin affinity Liver immaturity Lack of intestinal flora Breastfeeding Delayed/Inadequate feedings Blood incompatibility Preterm/Late preterm (immature conjugation abilities) Trauma at birth causing bruising/cephalohematoma Fatty acids from cold stress/asphyxia Polycythemia Family background Asian, American Indian, Native Alaskan heritage Sibling with jaundice Male gender Maternal diabetes or preeclampsia

What may interfere with a newborns ability to use brown fat

Hypoxia, hypoglycemia, & acidosis may interfere with infant's ability to use brown fat

What are preterm problems with nutrition

Lack certain nutrient reservoirs -minimal/absent fat stores Glucose reserves used soon after birth -hypoglycemia develops quickly Enteral feedings need to be 105-130 kcal/kg/day Should gain 15-20 g/kg/day GI tract doesn't absorb nutrients as well -do well with protein, not as well with fat Small stomach capacity

What is the importance of newborn's being less effective in fighting infection than older infants or children

Less able to localize infection (leads to tendency towards generalized sepsis) *Will see nonspecific signs of infection* -changes in activity, color, tone, & feeding rather than fever & increased WBC count you see in older kids Full term newborns receive antibodies from mom in last trimester Passive antibodies provided in breast milk Immunoglobulins help protect newborn from infection -IgG, IgM, & IgA Newborn total immunoglobulin levels at birth range from 55-80% of adult levels

What is done in newborn assessment

Make sure environment & equipment is ready ↑ room temp (feels warm to you) Over-bed warmer turned on & all the way up to high 2-3 blankets placed on over-bed warmer Something for suction, O2 delivery, hat, Know maternal & labor Hx Place baby on bed, timer set for 1 & 5 min for APGAR Dry & stimulate baby gently Apply hat, suction mouth then nose Observe color & monitor HR (Pink &HR above 100, screaming/crying = above 100) APGAR at 1 & 5 min scale 0-10 (appearance-pink, pulse->100, grimace-reaction to touch/stimulation, activity-tone/movement [flexed & movement], respiratory effort-on own/no distress) Change blankets, family present, cut/clamp cord, pics Get birth weight with blanket on scale Auscultate heart,lung, & bowel sound, vitals, & cap refill Observe appearance, skin, head, EENT, & fontanel's With glove feel hard & soft palate (cleft) & suck reflex Head ROM, feel clavicle for Fx, check for cyst on neck Check for S/S of jaundice Check genitals, anus & hernias -females: normal pink-white discharge -males: urinary meatus midline, scrotum pink/swollen, palpate distended testes, -anus: rectal temp, pass meconium in 1st 24 hrs, gluteal folds/skin folds even (void 1+ in 24 hrs, may occur at birth or take 12-24 hrs) Check baby backside (skin, spin straight, no opening/dimples/hair tufts) Check correct digits & no obvious abnormalities Check hips (feel joint for click with abduct and adduct) Get length & head circumference measurements Check reflexes (sucking, grasp, rooting, babinski, &startle) Listen for normal sounding cry Check response to touch (sensory responses normal)

What are S/S of phenylketonuria/PKU if untreated

May start with GI problems & later progress to seizures -musty odor urine & severe cognitive impairment Must follow low Phe diet -should start when Dx & continue throughout life (to avoid irreversible neurologic damage) Women with PKU not following diet closely -need to return to it before conceiving & during pregnancy to avoid abnormalities in fetus There is a special low Phe formula -low protein foods when time for solids Small amounts of Phe allowed (per age/body weight) -since it is a necessary amino acid

What is importance of mom being group B strep positive/GBS+

Mom that's GBS+ is a common cause of infection Requires vitals q 4 hr Mom is Tx with antibiotics during active labor

what is done in management of necrotizing enterocolitis/NEC

More studies show good results with probiotic use Encourage breastfeeding or use of donor milk Antibiotics, discontinuing oral feedings, continuous/intermittent gastric suction, use of parenteral nutrition to rest intestines Surgery to remove necrotic area with an ostomy -necessary if perforation/continued lack improvement Abdominal girth measured, manage IV fluids & parenteral nutrition, I/O, position on side (lessens diaphragm pressure from distended intestines)

What is the etiology of prenatal drug exposure

Most drugs readily cross placenta -cause various problems Neonatal abstinence syndrome/NAS -infants exposed to maternal drugs before birth demonstrate S/S of drug withdrawal Lack/No prenatal care or behavior in labor -may alert nurses to suspect maternal drug use S/S of NAS differ based on drug/combo of drugs used -often polysubstance abusers -often includes neuro/GI abnormalities

What are the norms of a post term infant assessment

Most normal if LGA -check for birth trauma injuries & hypoglycemia If postmaturity syndrome may have "stunned" look -from hypoxia Thin, loose skin, little subcutaneous fat Umbilical cord is thin with little Wharton's jelly Little or no vernix Long nails Skin is wrinkled, cracked, peeling Meconium might cause yellowish-green cord, skin, nails staining

What are the properties of S/S of polycythemia

Mostly mild or no signs Reddish skin tone Lethargy or irritability Poor tone Tremors -may have abdominal distention -decreased bowel sounds -poor feeding -hypoglycemia -respiratory distress -hyperbilirubinemia

What are major teaching topics for parents

Newborn characteristics & behavior Use of bulb syringe Breastfeeding & formula feeding Burping Cord care Care of penis, circumcised or uncircumcised Holding & positioning Sleep pattern & position Elimination patterns Bathing & skin care Clothing Signs of problems Taking a temp Infant safety Shaken baby syndrome Car seat use

Why is an IM vit. K injections given immediately following birth

Newborn has ↑ risk for hemorrhagic disease - 0.5-1.0 mg given within 1 hr of birth (delay until finished breastfeeding at birth)

How to perform neonatal resuscitation

Newborn is limp, blue, not breathing Dry & stimulate, suction Baby not responding, no respiratory effort Start positive pressure ventilation Check for effective ventilation No chest rise, adjust mask Do chest rise w/ HR q 30 sec w/ effective ventilation Apply pulse oximeter & ECG O2 up to 100%, Intubation & check placement Bilateral breath sounds & chest rise occur (CO2=yellow) Start compression's, 3 then 1 breath/1 min (respiratory & neonatologist on way) Re-evaluate, HR 48 & correlates w/ ECG Start compression's again, have epany?? Get out UVC (umbilical venous catheter) for IV access

What are interventions for preterm respiratory problems

O2 hood, nasal cannula, CPAP, mechanical ventilation Arterial or venous blood gases Pulse oximetry (provides continuous PO2 level info) Side-lying/prone positions (helps drain secretions & regurgitated feedings) Suction secretions

What causes the pulmonary blood vessels to constrict?

O₂ concentration as newborn takes first breaths

How are formula-fed infant stools described

Pale yellow-light brown Firmer in consistency May have several daily or just 1-2 Characteristic fecal odor

What are interventions for respiratory status

Positioning & suctioning secretions -shoulder roll -bulb syringe (mouth *then* nose) -nose if necessary (traumatic to delicate tissues; edema) -keep syringe in crib near infant's head -teach parents how to use -if mechanical/deep suction needed (use small cath, suction < 5 sec/time as cath's withdrawn) -continue to monitor -teach parents about (irregular respiratory pattern, periods of apnea, & mucus production during 2nd period of reactivity)

What are risk factors of sepsis

Prematurity & low birth weight -most important risk factors ROM longer than 12-18 hours Prolonged labor Signs of maternal infection before or during labor Chorioamnionitis Foul smelling amniotic fluid Healthcare associated infections in NICU

What are preterm problems with pain

Preterm infants feel pain -can cause physiologic and behavioral changes Intracranial pressure increase from pain -leads to increased risk for intraventricular hemorrhage Hypoxia, metabolic rate changes, adverse effects on growth & wound healing Stress & pain may alter pain thresholds & cause permanent changes in neural pathways Tissue injury early in development may lead to higher sensitivity to pain at site and surrounding areas Possibly long-term emotional, behavioral, & learning difficulties

What is done in therapeutic management of bronchopulmonary dysplasia/BPD

Prevention -use of maternal steroids -minimize exposure to O2 & pressure with ventilation -avoid fluid overload -increased nutrition Treatment -antibiotics and bronchodilators as necessary -gradually weaning oxygen -diuretics given/fluids restricted -increased calories and protein -often discharged home with O2 -frequent rehospitalizations (respiratory infections in first 2 years)

What is non-shivering thermogenesis

Primary method of heat production for newborns Metabolism of brown fat to produce heat -can ↑ heat production by 100% (brown fat contains abundant supply of blood vessels that causes the brown color) NST begins when thermal receptors in skin detect skin temp of 35-36°C, signal transmitted to hypothalamic thermal center, norepinephrine released in brown fat which starts its metabolism NST begins before core temp drops (rectal temp) -↓core temp won't occur until NST is no longer effective

What is the pathophysiology of meconium aspiration syndrome/MAS

Problem if meconium is passed & aspirated, air trapped behind meconium, causes overdistended alveoli which can lead to pneumothorax & infection of lung tissue Obstruction, chemical pneumonitis, & air trapping Tx with respiratory support (often sent to NICU) -ecmo, placenta acts as pump [does what lungs do] (heart lung bypass) -caused by meconium in the lungs Occurs mostly if hypoxia causes increased intestine peristalsis & relaxation of anal sphincter (before or during labor) Meconium in amniotic fluid enters lungs during fetal life or birth May be drawn into lungs if there are gasping movements in utero -due to asphyxia or acidosis -meconium may get pulled deep into respiratory passages when infant takes first breaths after birth May be partial or complete obstruction of the airways Atelectasis possible if small airways completely obstructed If they are partially obstructed, with inhalation: -bronchioles expand slightly with exhalation -passages constrict & meconium blocks air movement Results in "air trapping" -overdistended alveoli may develop an air leak (with air escape into pleural cavity/pneumothorax) Surfactant production may be inhibited -increases respiratory distress Meconium is irritating to lung tissue -causes inflammation & chemical pneumonitis Severe if meconium below vocal cords -not as common If lungs are already injured by asphyxia -addition of meconium makes it worse Injury from asphyxia interferes w/ clearing of lung fluid & production of surfactant -leads to pulmonary vasoconstriction -leads to return to fetal circulation patterns -leads to persistent pulmonary hypertension If "thin" meconium stained fluid, respiratory S/S may not develop Thick meconium may cause serious respiratory issues

What does IgA (immunoglobulin A) do

Protects GI & respiratory systems (newborn systems particularly susceptible to infections) Can't cross the placenta

What does IgG do

Provide passive temporary immunity to bacterial toxins, bacteria, & viruses mom developed immunity to Infant starts to produce own IgG slowly -gradually loses passive immunity from mother -significant IgG production starts at about 6 months -passive immunity reaches lowest level at 2-4 months

How is bilirubin removed from body

RBC hemolysis→ Unconjugated bilirubin→ Bloodstream→ Binds to albumin binding sites→ (if not, absorbed by subcutaneous fat causing jaundice if bad enough = staining of brain tissue) To liver & UDPGT enzyme breaks down→ Conjugated bilirubin→ Bile→ Duodenum & Intestinal flora→ Excreted (if not, beta-glucuronidase picks up &changes back into unconjugated bilirubin, enterohepatic circuit return it to the liver)

Why do infants of diabetic mothers have a higher risk for asphyxia & RDS

RDS, increased insulin levels block effect of cortisol on lung maturation Hypocalcemia, decreased parathyroid hormone production Magnesium levels may also be low Polycythemia from chronic hypoxia in utero leads to hyperbilirubinemia (when all RBC's break down after birth) More likely to be born prematurely

What is the enterohepatic circuit

Recirculation of bilirubin (creates more work for liver) -small amount of conjugated bilirubin may be deconjugated (converted back) to unconjugated state by intestinal enzyme *beta-glucuronidase* -this enzyme is needed for fetal life during pregnancy (only unconjugated bilirubin can be cleared by placenta for conjugation by mother's liver) -this means that bilirubin in newborn can be reabsorbed into circulation & carried back to liver to undergo conjugation process again

What is Fetal Growth Restriction (FGR)/Intrauterine Growth Restriction (IUGR)

Refers to infants full term, or close to, but failed to grow normally in uterus

What happens while a newborn is crying

Remaining fetal lung fluid moves out of lungs & is absorbed by pulmonary, circulatory & lymphatic systems -may take several hours to be completely absorbed -lungs may sound "wet" at first but clear short time later

What is circumcision

Removal of the foreskin that covers the glans penis

What is done during post procedural care of a circumcision

Remove from restraints/board immediately Petroleum jelly on site (if Gomco used) Piece of gauze over area Frequently check site for bleeding in 1st few hours after If excessively bleeding apply pressure to site & tell Dr (may apply Gelfoam, Epi, or suture small blood vessels) Note 1st urination after procedure (important because edema could cause obstruction)

What is RDS

Respiratory distress syndrome

What are common complications of preterm infants

Respiratory distress syndrome Bronchopulmonary dysplasia Intraventricular hemorrhage Retinopathy of prematurity Necrotizing enterocolitis Short bowel syndrome

How are breast-fed infant stools described

Seedy Mustard color/consistency More frequent than formula fed (4+ stools/day after day 4 of life)

What is the pathophysiology of necrotizing enterocolitis/NEC

Serious inflammatory condition of the intestinal tract -can lead to cellular death of areas of intestinal mucosa Exact cause unknown -immaturity of intestines a major factor -previous hypoxia of intestines may be causative factor Feeding too early/increased too fast may cause NEC With feeding: bacteria multiply/grow -gas forming organisms invade the intestinal wall -causes necrosis, perforation, & peritonitis Breast milk may have preventative effect

What is hydrops fetalis

Severe anemia results in heart failure & generalized edema

What is grunting

Soft moan with expiration -closes glottis & increases pressure within alveoli -concerning, don't want to hear

What describes preterm infant behavior

Stress of adjusting to extrauterine life before ready Little excess energy for maintaining muscle tone Easily exhausted by noise and routine activities Lowered O2 levels & stress-related behavior changes May have a feeble cry

What is done in therapeutic management of respiratory distress syndrome/RDS

Surfactant instilled in trachea after birth/when signs present Doses repeated if necessary Supportive treatment

What is sepsis neonatorum

Systemic infection from bacteria in the bloodstream Remember newborns' immune systems are immature and react slowly to invading organisms They have fewer antibodies & can't localize infection well -therefore it can spread easily Blood brain barrier less effective -can result in CNS infection Early onset -acquired during birth, signs show in first 3 days of life -from prolonged ROM/labor, chorioamnionitis -pneumonia & meningitis often present Late onset -acquired during or after birth -most commonly show signs after first week of life (often meningitis) Can be confused with other illnesses -often same initial S/S with other conditions like RDS Diagnostic testing helps identify sepsis & differentiate which organisms are responsible

What are S/S of sepsis

Temp instability (usually low) Feel infants not doing well Rash Tachypnea Respiratory distress Apnea Color changes Tachycardia Hypotension Decreased peripheral perfusion Edema Decreased oral intake Vomiting Excessive gastric residuals Diarrhea Abdominal distention Hypoglycemia/Hyperglycemia Decreased/Increased muscle tone Lethargy Jitteriness Irritability Full/Bulging fontanel High pitched cry Jaundice Evidence of hemorrhage Anemia Enlarged liver & spleen Respiratory failure Shock Seizures

Why can't IgM (immunoglobulin M) cross the placenta

The molecules are too large

What happens to the 3 shunts at birth

The shunts CLOSE & pulmonary vessels dilate (widen & open) in response to ↑ blood oxygen & shifts in pressure within the heart, pulmonary, & systemic circulations, as well as clamping of the umbilical cord

What are external causes of the respiration

Thermal, Sensory, & Mechanical factors -cold air & touch stimulate skin sensors -impulses from skin sensors & responses to sound & light affect respiratory center -newborn draws first breath *Or* -chest compression & release during birth cause air to be drawn into lungs -newborn draws first breath

What characteristics predispose newborns to lose heat

Thin skin; blood vessels close to surface Little subcutaneous (white) fat present to act as barrier 3x more BSA to BMI than adults (more area for heat loss) If sick or preterm; lose heat even more easily (thinner skin/less white fat/not maintain flexed position)

What is the pathophysiology or respiratory distress syndrome/RDS

Too little surfactant present -alveoli collapse each time the infant exhales Lungs become noncompliant (stiff) & resist expansion Noncompliant lungs need higher neg pressure -to open alveoli, causes retractions Less alveoli expand -causes atelectasis, hypoxia, hypercapnia -causes pulmonary vasoconstriction & decreased blood flow to lungs -causes persistent pulmonary hypertension -can lead to return to fetal circulation (opening of ductus arteriosus/DA) Amniotic fluid tests can detect surfactant components -lecithin, sphingomyelin, phosphatidylglycerol, & phosphatidylinositol -predicts if fetal lungs mature enough to survive outside uterus -incidence & severity of RDS may be reduced by giving mom corticosteroids before birth

What is the pathophysiology of persistent pulmonary hypertension of the newborn/PPHN

Usually happens in term or post term infants Pulmonary vasoconstriction occurs after birth & increases vascular resistance in the lungs Therefore normal changes from fetal -leads to neonatal circulation cannot occur or "persistent fetal circulation" May be caused by abnormal lung development, maternal use of NSAID's or SSRI's, or unknown cause Often associated with hypoxemia & acidosis from certain conditions (asphyxia, MAS, sepsis, etc) As with other respiratory babies -handling & activity kept to a min. to avoid hypoxia Maintain temperature Monitor for complications -hypoglycemia, hypocalcemia, anemia, metabolic acidosis

When is meconium normally passed in stool

Usually within 12 hours (99% by 48 hours)

What are characteristics of late preterm infants

Varies a lot according to gestational age (ex. 26 weeks versus 34 weeks) but some are common among all

What blood samples are more accurate

Venous blood samples are more accurate (peripheral circulation is sluggish)

What is vertical & horizontal infections

Vertical infection -acquired before or during birth from mother -can cross placenta during pregnancy (rubella, cytomegalovirus/CMV, syphilis, HIV, toxoplasmosis) -can enter uterus after ROM -can infect during passage through birth canal (GBS, herpes, hepatitis) Horizontal infection [after birth] -acquired from hospital staff, equipment or visitors

Where is vitamin K made & what is needed

Vit. K is made in the intestines Need food & normal intestinal flora for this process -at birth intestines are sterile & can't produce vit. K

What are interventions to prevent heat loss

Warm radiant warmer before birth Skin-to-skin or under radiant warmer right after birth Dry quickly with towels, especially hair Replace towels/blankets immediately with dry ones Place hat if not under warmer Set servo-control if infant is under warmer (place sensor on abdomen)

The parents of a 24 hr old newborn are worried about their baby girl after the pediatrician rounded this morning, saying "He mentioned that she has a little jaundice but didn't seem to care. Don't we need to do the lights?" What can you teach the parents about jaundice? What can you teach them to do to help prevent jaundice?

When normal vs abnormal jaundice appears Normal peak of jaundice at 2-5 days -their baby is only slightly jaundiced which is normal (liver is immature & takes longer to break down bilirubin) That you're monitoring closely for jaundice to worsen -if it does you will obtain a blood sample When phototherapy is necessary -only if bilirubin reaches a certain point & is worsening (not necessary for normal & mild jaundice) Importance of frequent feedings -eating often, encourages stools (how bilirubin is excreted from the body)

Is temporary hyperbilirubinemia considered normal

Yes, Temporary hyperbilirubinemia is considered normal

You are a newborn nurse preparing to administer the erythromycin eye ointment to an infant born 30 min ago. The mother becomes upset & offended, stating "she doesn't have an STD & her husband doesn't cheat on her". What do you say to the mother?

You understand her concern about the eye ointment Explain it's required by law for ALL infants -r/t high blind risk w/ infection from mom in delivery -extremely beneficial & necessary preventative measure (because of the risk of seriousness) She has right to refuse after hearing the risks

The nurse is assessing a newborns circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement? a. Apply pressure to the site. b. Continue to observe for another 30 minutes. c. Apply the diaper tightly over the circumcised area. d. Apply petroleum jelly to the site with a small piece of gauze.

a. Apply pressure to the site.

Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp

a. Babinski

The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

a. Depress the tip of the nose. (skin blanching)

An infant at 36 weeks gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading? a. Document the finding in the newborns chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.

a. Document the finding in the newborns chart.

A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse? a. Encourage the parents to touch their infant. b. Reassure the parents that the infant is progressing well. c. Discuss care they will give their infant when the infant goes home. d. Suggest the parents visit for only short time to reduce anxiety.

a. Encourage the parents to touch their infant.

Which newborn assessment finding requires the nurse to take an action? a. Glucose level of 40 mg/dL b. Axillary temperature of 37 C (98.6 F) c. Mild yellow tinge to skin at 32 hours of age d. Mild inflammation of conjunctiva after eye prophylaxis

a. Glucose level of 40 mg/dL

Decreased surfactant production in the preterm lung is a problem because: a. Surfactant keeps the alveoli open during expiration. b. Surfactant causes increased permeability of the alveoli. c. Surfactant dilates the bronchioles, decreasing airway resistance. d. Surfactant provides transportation for oxygen to enter the blood supply.

a. Surfactant keeps the alveoli open during expiration.

A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base a reply? a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection. c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly

a. The yellow crust should not be removed.

Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.

a. Turn the infant every 2 hours.

While caring for a post-term infant, the nurse recognizes that the elevated hematocrit level most likely results from: a. hypoxia in utero. b. underproduction of red blood cells. c. increased breakdown of red blood cells. d. the normal expected shift from fetal hemoglobin to normal hemoglobin.

a. hypoxia in utero.

A newborn assessment finding that would support the nursing diagnosis of postmaturity would be: a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.

a. loose skin. (loss of subcutaneous tissue)

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of: a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.

a. persistent pulmonary hypertension.

The priority assessment for the Rh-positive infant whose mothers indirect Coombs test was positive at 36 weeks is: a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.

a. skin color. (erythroblastosis fetalis pallor)

What is oligohydramnios

amniotic fluid vol. < than expected for gestational age

The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborns chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mothers chart? a. Racenon-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section

b. A longer than usual labor

Which is the most likely cause of regurgitation when a newborn is fed? a. The gastrocolic reflex b. A relaxed cardiac sphincter c. An underdeveloped pyloric sphincter d. Placing the infant in a prone position following a feeding

b. A relaxed cardiac sphincter

Which is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families with Dependent Children d. Women, Infants, and Children (WIC) nutritional program

b. Adequate prenatal care

Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for: a. Hyperglycemia. b. Clavicle fractures. c. Hyperthermia. d. An increase in red blood cells.

b. Clavicle fractures.

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation

b. Conduction

A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels

b. Metabolic acidosis

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of: a. RDS. b. PIVH. c. BPD. d. ROP.

b. PIVH. (IVH)

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70 F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

b. Place a blanket over the scale before weighing the infant.

Which should the nurse implement to prevent the kidnapping of a newborn from the hospital? a. Restricting the amount of time infants are out of the nursery b. Question anyone seen walking in hallways carrying an infant c. No visitors in maternity area except those with ID bracelets d. Instruct parents to not give baby to anyone except nurse

b. Question anyone seen walking in hallways carrying an infant

In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem? a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours. b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn. c. Make sure that all emergency exits are accessible to staff and clients on the unit. d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.

b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn.

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Intraventricular hemorrhage (IVH) d. Bronchopulmonary dysplasia (BPD)

b. Retinopathy of prematurity (ROP)

The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct? a. Depress the bulb prior to inserting the tip. b. Suction the nose first and then the mouth. c. Keep a bulb syringe in the bassinet at all times. d. Gradually release the pressure on the bulb while withdrawing it.

b. Suction the nose first and then the mouth.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D5W. d. Document the event in the nurses notes.

b. Test for the blood glucose level.

An infant delivered preterm at 28 weeks gestation weighs 1200 g. Based on this information, the infant is designated as: a. SGA. b. VLBW. c. ELBW. d. Low birth weight at term.

b. VLBW. (birth weight = 1500 g or less)

The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8 to 37 C (98.2 to 98.6 F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision? a. Consent b. Vitamin K c. Heart rate d. Temperature

b. Vitamin K

Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? a. The nurse will draw blood to determine if vitamin K is needed. b. Vitamin K prevents possible bleeding problems in my baby. c. My baby will receive a shot when nurse administers the vitamin K. d. Vitamin K is administered shortly after birth, generally in first hour.

b. Vitamin K prevents possible bleeding problems in my baby.

The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice: a. usually results in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.

b. appears during the first 24 hours of life.

When an infants temperature drops from 98.7 to 97.4 F (37 to 36.3 C), the nurse should: a. instruct parents on cold stress. b. determine time and amount of last feeding. c. increase the temperature in the mothers room. d. evaluate infant for a blood sugar level higher than 50 mg/dL.

b. determine time and amount of last feeding.

Following a traumatic birth of a 10-pound infant, the nurse should assess: a. gestational age status. b. flexion of both upper extremities. c. infants percentile on growth chart. d. blood sugar to detect hyperglycemia.

b. flexion of both upper extremities. (clavicle Fx)

Parents ask the nurse, What makes the opening between the babies atrium's close at birth? The nurses response is that cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. changes in the hepatic blood flow. b. increased pressure in the left atrium. c. increased pressure in the right atrium. d. decreased blood flow to the left ventricle

b. increased pressure in the left atrium.

Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

b. jaundice.

The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of: a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.

b. neonatal infection. (sepsis)

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeedings is to: a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.

b. provide fluids and protein.

During fetal circulation the pressure is greatest in the: a. left atrium. b. right atrium. c. hepatic system. d. pulmonary veins.

b. right atrium.

The nurses immediate action after the birth of a post-term infant with meconium stained amniotic fluid is to: a. stimulate the infant to cry. b. suction the infants airways. c. complete the 1 and 5 minute APGAR's. d. vigorously dry the infants head and trunk.

b. suction the infants airways.

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment? a. 24 to 27 C (75.2 to 80.6 F) b. 28 to 31.5 C (82.4 to 88.7 F) c. 32 to 33.5 C (89.6 to 92.3 F) d. 34 to 37.5 C (93.2 to 99.5 F)

c. 32 to 33.5 C (89.6 to 92.3 F)

Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome? a. 35-week-gestation vaginal baby to heroin addicted mom b. 35-week-gestation vaginal baby 72 hr after rupture of membranes c. 36-week-gestation c-section baby to insulin-dependent diabetes mom d. 35-week-gestation vaginal baby to pregnancy-induced HTN mom

c. 36-week-gestation c-section baby to insulin-dependent diabetes mom

The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? a. 38-weeks gestation newborn with blood sugar of 60 mg/dL b. Term newborn with noted axillary temperature of 37.2 C (99 F) c. 40-weeks gestation newborn reported poor feed at last attempt d. 39-weeks gestation newborn been crying prior to initial bath

c. 40-weeks gestation newborn reported poor feed at last attempt

An hour after birth, the nurse assesses a newborns temperature and notes that it is 36.2 C (97.2 F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurses next action? a. Take the infants temperature rectally. b. Ask the father to test the water to determine if it is too hot. c. Delay bath until newborn temp is above 36.7 C (98 F). d. Explain to new parents no soap should be used to clean the eyes.

c. Delay bath until newborn temp is above 36.7 C (98 F)

How can nurses prevent evaporation heat loss in the newborn? a. Placing baby away from the outside wall and the windows b. Keeping baby out of drafts and away from air conditioners c. Drying baby after birth and wrapping the baby in a dry blanket d. Warming stethoscope & nurses hands before touching baby

c. Drying baby after birth and wrapping the baby in a dry blanket

An infant with severe meconium aspiration syndrome is not responding to conventional treatment. Which method of treatment may be available at a level III facility for use with this infant? a. Insertion of an endotracheal tube b. Respiratory support with a ventilator c. Extracorporeal membrane oxygenation d. Insertion of a laryngoscope and suctioning of the trachea

c. Extracorporeal membrane oxygenation

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity r/t diarrhea as a result of phototherapy c. Fluid volume deficit r/t phototherapy treatment d. Knowledge deficit (parents) r/t initiation of medical therapy

c. Fluid volume deficit r/t phototherapy treatment

A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

c. Greater than the 90th

Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths/min d. Has an axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respiration's of 54 breaths/min

c. Has a sustained respiratory rate of 70 breaths/min (indicates a respiratory problem)

A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the mother. Which procedure is correct for identifying the newborn? a. Ask the mother to state her name and the name of her infant. b. Call out the mothers full name before leaving the infant with her. c. Have mom read her band number & verify it matches the infants d. Return infant w/o special procedure, student knows mom & infant

c. Have mom read her band number & verify it matches the infants

Which defect is present with tetralogy of Fallot? a. Patent ductus arteriosus b. Coarctation of the aorta c. Hypertrophy of the right ventricle d. Transposition of the great arteries

c. Hypertrophy of the right ventricle

A 38 weeks gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. APGAR scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis? a. Risk for injury r/t possible equipment malfunction, radiant warmer b. Altered tissue perfusion r/t use of med's during delivery process c. Ineffective airway clearance r/t delivery route & use of anesthetics d. Risk for ineffective thermoregulation related to gestational age

c. Ineffective airway clearance r/t delivery route & use of anesthetics

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type

c. Infant bilirubin level

A reported hematocrit level for a newborn vaginal birth is 75%. Based on this lab value, which complication is the newborn least at risk to develop? a. Hypoglycemia b. Respiratory distress c. Infection d. Jaundice

c. Infection

What should the nurse teach to parents about using a bulb syringe? a. Use it only once a day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the nose before the mouth.

c. Insert the syringe into the sides of the mouth.

A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respiration's. The infants color and heart rate remain unchanged. The nurse suspects that the infant: a. Is exhibiting signs of RDS. b. Requires tactile stimulation 24/7 to ensure apneic periods don't worsen c. Is experiencing periodic breathing episodes, requires continuous monitoring while in nursery unit. d. Requires the use of CPAP to promote airway expansion.

c. Is experiencing periodic breathing episodes, requires continuous monitoring while in nursery unit.

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice.

c. It is not initially synthesized because of a sterile bowel at birth.

A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. The red appearance of my babies skin is due to an excessive number of red blood cells. b. My baby will be watched closely for signs of low blood sugar, especially during the early days after birth. c. My babies pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy. d. Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be.

c. My babies pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy.

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which should the nurse include as an explanation of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.

c. Newborns have increased glucose demands.

Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respiration's

c. Pause in breathing lasting 20 seconds

Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infants growth

c. Perform an expanded assessment.

While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection r/t release of meconium b. Risk for injury r/t high-risk birth interventions, like amino infusion c. Risk for aspiration r/t retained secretions d. Risk for thermoregulation because of high-risk labor status

c. Risk for aspiration r/t retained secretions

What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a. All body parts appear proportionate. b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body. d. One side of the body appears slightly smaller than the other.

c. The head seems large compared with the rest of the body.

The nurse present at the birth is reporting to the nurse who will be caring for the neonate after birth. Which information should be included for an infant who had thick meconium in the amniotic fluid? a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. There was no meconium below vocal cords when visualized. d. Infant needed vigorous stimulation immediately to initiate crying.

c. There was no meconium below vocal cords when visualized.

Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is only recognized cause of this condition

c. They are below the tenth percentile on gestational growth charts.

Which statement is most true about large-for-gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

c. They are prone to hypoglycemia, polycythemia, and birth injuries.

The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching? a. We understand the tests are performed at 24 to 48 hours. b. Were glad all the tests can be done on one blood sample. c. We wish the tests would screen for congenital hypothyroidism. d. We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks.

c. We wish the tests would screen for congenital hypothyroidism.

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin.

c. conjugation of bilirubin.

Inspection of a newborns head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn, anticipate molding will subside. b. inspect & document fontanel location to complete head exam c. contact the neonatologist. d. note findings as in normal limits as result of strenuous birth

c. contact the neonatologist.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of: a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal birth associated with meconium-stained fluid.

c. delayed absorption of fetal lung fluid.

Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical condition. The best action that the nurse can take at this time is to: a. refer them to the neonatologist for more information. b. tell them not to worry, their infant will be monitored closely. c. explain that this often occurs following birth, most likely resolved in 24-48 hr. d. tell them they can come see their baby, helps them feel better.

c. explain that this often occurs following birth, most likely resolved in 24-48 hr.

The nurse should be alert to a blood group incompatibility if: a. both mother and infant are O-positive. b. mother is A-positive and infant is A-negative. c. mother is O-positive and infant is B-negative. d. mother is B-positive and infant is O-negative.

c. mother is O-positive and infant is B-negative.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. seen at 3 days of age. b. the residue of a milk curd. c. passed in the first 24 hours of life. d. lighter in color and looser in consistency.

c. passed in the first 24 hours of life.

When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find: a. cyanosis. b. diuresis. c. signs of pulmonary congestion. d. increased oxygenation of the tissues.

c. signs of pulmonary congestion.

Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infants weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. 3 successive temperature measurements were 97, 96, and 97 F.

d. 3 successive temperature measurements were 97, 96, and 97 F.

Newborns whose mothers are substance abusers frequently have which behaviors? a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased sleep, hyperactive Moro reflex, and difficulty feeding

d. Decreased sleep, hyperactive Moro reflex, and difficulty feeding

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels

d. Dilation of pulmonary vessels

Which of the following lab values indicates that an infant may have polycythemia? a. Hb 18 g/dL, Hct 50% b. Hb 25 g/dL, Hct 55% c. Hb 20 g/dL, Hct 65% d. Hb 30 g/dL, Hct 70%

d. Hb 30 g/dL, Hct 70% (Hb > 22 & Hct > 65)

Which principle is important in providing and teaching cord care? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth.

d. Keeping the cord dry will decrease bacterial growth.

An infants temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure infant is wrapped securely w/ blanket & recheck temp in 15 min.

d. Make sure infant is wrapped securely w/ blanket & recheck temp in 15 min.

A multiparous patient arrives to the labor unit and urgently states, The baby is coming RIGHT NOW! The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patients room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patients abdomen after the cord is cut.

d. Place the baby on the patients abdomen after the cord is cut.

Which action by the nurse can cause hyperthermia in the newborn? a. Placing a cap on the newborn b. Wrapping the newborn in a warm blanket c. Placing the newborn in a skin to skin position with the mother d. Placing the newborn in the radiant warmer without attaching the skin probe

d. Placing the newborn in the radiant warmer without attaching the skin probe

Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration. c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings.

d. Prevent hypoglycemia with early and frequent feedings.

To determine a preterm infants readiness for nipple feeding, the nurse should assess the: a. Skin turgor. b. Bowel sounds. c. Current weight. d. Respiratory rate.

d. Respiratory rate. (<60/min)

The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first? a. Glucose water b. D5W intravenously c. Formula via nasogastric tube d. Small amount of glucose water followed by formula or breast milk

d. Small amount of glucose water followed by formula or breast milk

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. Keep charts on top of incubator so nurses can write them there. c. While giving report stand in front of incubator & talk softly d. Teach parents overstimulation S/S, like turning face away or stiffening & extending extremities & fingers.

d. Teach parents overstimulation S/S, like turning face away or stiffening & extending extremities & fingers.

Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature d. The infant who is breastfed during the first hour of life

d. The infant who is breastfed during the first hour of life

A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information? a. This is an emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of c-section baby may sound moist for 24 hr after birth.

d. The lungs of c-section baby may sound moist for 24 hr after birth

Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn? a. Deltoid muscle b. Gluteal muscles c. Rectus femoris muscle d. Vastus lateralis muscle

d. Vastus lateralis muscle

The infants heat loss immediately at birth is predominantly from: a. radiation. b. conduction. c. convection. d. evaporation.

d. evaporation.

In an infant with cyanotic cardiac anomaly, the nurse should expect to see: a. feedings taken eagerly. b. a consistent and rapid weight gain. c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration.

d. little to no improvement in color with oxygen administration.