Ch. 20 The Newborn At Risk: Gestational & Acquired Disorders
A newborn has been diagnosed recently with transient tachypnea of the newborn. How should the nurse counsel the parents? "Although this condition is very treatable, it is most likely caused by an infection, and we will need to start him on antibiotics." "I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run." "Unfortunately, there isn't any treatment for this condition. We will need to show you how to monitor your baby at home, particularly for blueness around the mouth." "This is happening because your baby was born via cesarean. If you had had a vaginal delivery, this wouldn't be happening."
"I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run." Explanation: Although it is more common for newborns who are born via cesarean delivery to develop TTN, a newborn who is born vaginally may also exhibit TTN. TTN usually resolves on its own and does not affect the newborn in the long run. TTN usually is not caused by infection, although it may be a sign of infection. Although mild respiratory distress is common in newborns who have TTN, cyanosis is not.
A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by the parents indicates that additional teaching is needed? Select all that apply. "The harness needs to be removed for bathing." "The harness must be removed for diaper changes and for feeding." "The harness can be removed when the baby is awake." "The infant's skin needs to be checked for redness when the harness is removed." "The infant should wear the harness 23 hours a day."
"The harness can be removed when the baby is awake." "The harness must be removed for diaper changes and for feeding." Explanation: The statement about removing the harness when the baby is awake and for diaper changes and feedings indicates a need for additional teaching. The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing.
A newborn has been diagnosed with retinopathy of prematurity. The nurse is teaching the parents about this condition. Which statement would the nurse most likely include in the teaching? "Let's talk about the surgery that will be needed." "You'll need to schedule follow-up eye examinations with the pediatric ophthalmologist." "You'll need to give the eye drops each day for the next few weeks." "It's difficult now, but rest assured that your baby will grow out of it."
"You'll need to schedule follow-up eye examinations with the pediatric ophthalmologist." Explanation: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination. Surgery may or may not be needed. Eye drops are not used. Some children do grow out of it, but it is inappropriate for the nurse to assume that this is the case with this child.
The incidence of sudden infant death syndrome (SIDS) peaks at what age? During the neonatal period 1 to 2 months 2 to 4 months 4 to 6 months
2 to 4 months Explanation: The incidence of SIDS is highest at 2 to 4 months of age.
If a newborn whose weight, length, and head circumference falls into the 15th percentile for gestational age, the newborn would be said to be which of the following? Post-term for gestational age Small for gestational age Appropriate for gestational age Preterm for gestational age
Appropriate for gestational age Explanation: Appropriate for gestational age (AGA) describes a newborn whose weight, length, and/or head circumference falls between the 10th and 90th percentiles for gestational age.
A late preterm newborn is born at: Between 32 and 34 weeks Between 32 and 36 weeks Between 34 and 36 weeks Between 34 and 37 weeks
Between 34 and 37 weeks Explanation: The late preterm newborn is born between 34 and 37 weeks. This is an important classification of newborns because their care may differ from that provided to other preterm infants.
The nurse is preparing to administer a tube feeding to a preterm infant. When checking for residual prior to the feeding, there is a residual of 3 mL. What action should the nurse take? Call the physician. Reduce the amount of the tube feeding by half. Administer the tube feeding. Take the tube out.
Call the physician. Explanation: The nurse should report immediately gradually increasing residual and abdominal girth or return of more than 2 mL of undigested formula. These signs indicate feeding intolerance and could herald the onset of necrotizing enterocolitis (NEC).
For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin? Group B streptococcus Herpes simplex virus Type 1 Chlamydia trachomatis Human immunodeficiency virus
Chlamydia trachomatis Explanation: Ophthalmic erythromycin is routinely provided to the newborn after birth to prevent acquiring a Chlamydia trachomatis or Neisseria gonorrhoeae infection during vaginal birth. IV antibiotics are used to treat a Group B streptococcus infection. Antiviral therapy is given to neonates with herpes simplex and human immunodeficiency virus.
The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant? Middle crease across the palm of the hand No deep creases on the newborn's body Creases covering two-thirds of the anterior foot Creases extending across the brow
Creases covering two-thirds of the anterior foot Explanation: On the Ballard Scale, an assessment and documentation of a crease covering two-thirds of the anterior foot is interpreted as characteristic of a full-term newborn. The creases are assessed on the foot, not the hand or brow. No creases are indicative of a preterm newborn.
The nurse is instructing a diabetic mother on the complications associated with uncontrolled blood glucose levels. Which complication is most concerning? Macrosomia Delayed lung maturity Hyperbilirubinemia Hypoglycemia after birth
Delayed lung maturity Explanation: High insulin levels can delay fetal lung maturity resulting in respiratory distress. Surfactant therapy may be needed. Hypoglycemia can be avoided by beginning feeding soon after birth or using IV glucose. Hyperbilirubinemia can be corrected with fluids or phototherapy. Reducing macrosomia and the build-up of fat deposits will occur over time.
At which point is the treatment (RhoGAM) for the hemolytic disease of the newborn finished? During the postpartum period It is no longer needed after the first pregnancy. During the prenatal period Immediately before delivery
During the postpartum period Explanation: The treatment for Rh incompatibility is RhoGAM; it is given to prevent complications during the second pregnancy and is administered in the postpartum period. This prevents antibodies from entering fetal circulation and hemolyzing or destroying the fetus's RBC.
Which of the following best describes the time between fertilization of the egg and birth? Trimesters Signs of pregnancy Gestational age Intrauterine growth
Gestational age Explanation: Gestational age is the length of time between fertilization of the egg and birth.
Which interventions would the nurse implement for an infant with diaphragmatic hernia? Select all that apply. Elevate head of bed. Initiate breastfeeding. Insert a chest tube. Administer oxygen by nasal cannula. Insert a nasogastric tube.
Insert a nasogastric tube. Elevate head of bed. Explanation: A nasogastric tube is inserted, and the infant is NPO to prevent the distention of the herniated intestine and to avoid further respiratory difficulty. The head of bed is elevated to allow the herniated intestine to fall back as far as possible into the abdomen and to allow the unaffected lung to expand more completely. Nasal cannula oxygen is not effective because the affected lung is not expanded. A chest tube is not effective because the herniated intestine is preventing expansion of the lung.
What is the most common reason why an infant will be small for gestational age (SGA)? Intrauterine growth restriction Placenta previa Hyperemesis gravidarum Oligohydramnios
Intrauterine growth restriction Explanation: Intrauterine growth restriction caused by a multitude of factors is the most common reason why an infant will be small for gestational age.
Why does breathing require greater effort for the preterm newborn? Lack of surfactant Lack of a hyaline membrane Lack of a fibrous membrane Lack of alveoli
Lack of surfactant Explanation: Preterm infants are born with less surfactant than term infants. Surfactant keeps the lungs partially expanded after each breath. An inadequate amount of surfactant causes the lungs to collapse after each breath, requiring the preterm infant to use more energy and effort to keep breathing.
A newborn admitted to the nursery weighs 2,000 grams. This newborn is classified as which of the following? High birth weight Normal birth weight Very low birth weight Low birth weight
Low birth weight Explanation: The classification of a low birth weight (LBW) is a newborn that weighs less than 2,500 grams (g).
The nurse is teaching a primigravida factors influencing the status of her pregnancy. Which maternal lifestyle factors have a risk of causing a preterm birth? Select all that apply. Maternal diet Overworked Fetal infection Maternal age extremes Low income Living conditions
Maternal age extremes Low income Maternal diet Living conditions Overworked Explanation: Premature births may result from maternal lifestyle conditions which impact the fetus negatively. These factors include maternal age extremes (teenage years and over age 35), low income, maternal diet, unfavorable living conditions, and mothers who are overworked. Fetal infection may be a result of the maternal lifestyle.
When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? Acetaminophen Morphine Ibuprofen Aspirin
Morphine Explanation: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid narcotic, is given to the client to ease the withdrawal symptoms and also gradually remove narcotics from the system. The other options do not ease withdrawal symptoms.
When a fetus has chronic hypoxia in utero, what response does the nurse expect to see after birth? Sickle-cell anemia Iron-deficiency anemia Polycythemia Polyhydramnios
Polycythemia Explanation: In response to chronic hypoxia in utero, the fetus increases red blood cell (RBC) production, leading to polycythemia (excess number of RBCs) and hyperviscosity of the blood.
Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs? Provide a dark, quiet environment Play soothing music Offer tactile stimulation Incorporate a massage
Provide a dark, quiet environment Explanation: A dark and quiet environment provides relaxation and allows the opportunity for the neonate to withdraw from the alcohol and drugs without becoming overstimulated. Massage and tactile stimulation can stimulate the neonate, leading to seizures. A dark environment is more helpful than soothing music.
The student nurse is performing a Ballard scale on a newborn. The instructor assesses that the student understands methods to check neuromuscular maturity when she gently pulls the newborn's arm in front of and across the top portion of the body until resistance is met and identifies this action as: Arm recoil. Popliteal angle. Square window. Posture. Scarf sign.
Scarf sign. Explanation: Scarf sign is accomplished by gently pulling the newborn's arm in front of and across the top portion of the body until resistance is met as a measure of neuromuscular maturity. Popliteal angle and posture do not require manipulation of the arm. Square window and arm recoil do not require the nurse to move the arm across the chest.
Which preventable cause of intrauterine growth restriction (IUGR) is most common? Hypertension Alcohol use Gestational diabetes Smoking
Smoking Explanation: Smoking is the most common preventable cause of IUGR. Hypertension and gestational diabetes are not entirely preventable. Alcohol use is not as common as smoking.
The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort? Promote parental bonding Administer benzodiazepines Swaddle and decrease stimulation Provide 1 ounce of formula
Swaddle and decrease stimulation Explanation: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.
The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate? The infant was a preterm, low birth weight and small for gestational age neonate. The infant was a preterm, very low birth weight and small for gestational age. The infant was born at term but a very low birth weight and small for gestational age. The infant was born at term but at a low birth weight and small for gestational age.
The infant was a preterm, low birth weight and small for gestational age neonate. Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2,500 g) and small for gestational age at the 8th percentile (under the 10th percentile). The other documentations are not accurate.
The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? The large for gestational age neonate The neonate born at 41 weeks' gestation The neonate delivered by cesarean section The neonate whose mother received limited prenatal care
The neonate delivered by cesarean section Explanation: While every neonate has the respiratory system assessed, some are at higher risk of complications than others. The neonate born via cesarean section is at highest risk for TTN since this infant did not have the opportunity of having fluid expressed from the lungs as he/she descended down the birth canal. The other options are not in the high-risk category.
After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia? inhaled surfactant antibiotics suction of the oropharynx intubation
antibiotics Explanation: Prophylactic antibiotics may prevent development of pneumonia.
The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: cries when touched. has facial deformities. weighed above average when born. sleeps for long periods of time.
cries when touched. Explanation: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born.
The pregnant woman with diabetes asks the nurse why her last baby weighed 11 pounds. What is the best response by the nurse? "The fetus maintains elevated levels of glucose in response to the mother's eating patterns and gains too much weight." "Your baby weighed so much because of how you were eating. You must eat less with this child." "There is no way to control the amount of glucose the mother is producing, because she can't take insulin while she is pregnant and the baby gains too much weight." "The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone."
"The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone." Explanation: Consistently elevated fetal insulin levels cause the distinctive growth pattern. Because maternal glucose levels are elevated and glucose readily crosses the placenta, the fetus responds by increasing insulin production. Because insulin acts as a fetal growth hormone, consistently high levels cause fetal macrosomia, birth weight of greater than 4,500 g. Insulin also causes disproportionate fat buildup to the shoulders and upper body, increasing the risk for shoulder dystocia and birth trauma.
A newborn has been diagnosed with retinopathy of prematurity. The nurse is teaching the parents about this condition. Which statement would the nurse most likely include in the teaching? "You'll need to schedule follow-up eye examinations with the pediatric ophthalmologist." "It's difficult now, but rest assured that your baby will grow out of it." "You'll need to give the eye drops each day for the next few weeks." "Let's talk about the surgery that will be needed."
"You'll need to schedule follow-up eye examinations with the pediatric ophthalmologist." Explanation: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination. Surgery may or may not be needed. Eye drops are not used. Some children do grow out of it, but it is inappropriate for the nurse to assume that this is the case with this child.
When thick meconium is present in a term infant, the neonate will not produce a spontaneous cry. Place the following steps in the order in which they should occur. 1. Perform gastric lavage 2. Deliver the newborn 3. Call a health care provider skilled in intubation to the delivery room 4. Intubate the newborn 5. Suction the airway below the vocal cords
1. Call a health care provider skilled in intubation to the delivery room 2. Deliver the newborn 3. Intubate the newborn 4. Suction the airway below the vocal cords 5. Perform gastric lavage Explanation: When thick meconium is present in a term infant, a practitioner who is able to perform newborn intubation should be present in the delivery room. After delivery of the newborn, the infant is intubated and the airway is suctioned. Gastric lavage may be performed if meconium is swallowed.
What percentage of newborns are born with a complication or develop one shortly after birth? 1% 10% 18% 5%
10% Explanation: 10% of newborns are born with a complication or develop a complication shortly after birth.
The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks gestation? 42 weeks 41 weeks 44 weeks 40 weeks
42 weeks Explanation: The nurse is most correct to state that mothers do not progress longer than 42 weeks gestation. At that point, either a cesarean section or an induction would be completed. Actual dates do vary depending on the status of the fetus.
Why is thermoregulation a problem for the preterm newborn? A preterm infant is not born with brown fat. A decrease in skin surface to body mass is noted. Water cannot escape easily through the skin. The CNS is overactive, leading to excessive shivering and use of glucose stores.
A preterm infant is not born with brown fat. Explanation: A preterm infant is not born with brown fat; this leads to easy heat and water loss through the skin. An increase in skin surface to body mass causes heat to be lost more easily. The CNS is immature, and the preterm infant usually cannot shiver.
All of the following complications are more likely to develop in a large for gestational age (LGA) newborn as opposed to an appropriate for gestational age (AGA) newborn except: Breech presentation Shoulder dystocia Polycythemia Cesarean delivery
Explanation: Polycythemia is more likely to occur in a small for gestational age (SGA) newborn as a response to persistent oxygen deprivation. Cesarean delivery, breech presentation, and shoulder dystocia are all more likely to occur in an LGA infant.
The nurse in the nursery is told that a neonate at 32 weeks' gestation has been born. What adjustment in nursing care will the nurse make? Select all that apply. Provide a stimulating environment Open IV equipment. Obtain a gram scale. Have an incubator with oxygen, if needed, ready. Set up an apnea monitor. Reposition neonate every 2 hours.
Have an incubator with oxygen, if needed, ready. Reposition neonate every 2 hours. Open IV equipment. Obtain a gram scale. Set up an apnea monitor. Explanation: The neonate is born at least 5 weeks early. Due to the characteristics of a preterm neonate, nursing care is different. A warmed incubator is used as the neonate has thin skin and little subcutaneous fat. Every effort is made to keep the baby warm. Oxygen is available, if needed. Due to the fragility of the skin, reposition the neonate every 2 hours so that no breakdown occurs. The client typically has an IV as medications are delivered through this route. Also, a vein is opened if needed. Preterm neonates also have difficulty breathing. An apnea monitor with heart rate and oxygen saturation is best. Obtain a gram scale for measurement of accurate output. Limited stimulation is best.
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? Risk for injury related to the very thin epidermis layer of skin Imbalanced nutrition: Less than body requirements related to the premature digestive system Grieving related to the loss of "a healthy full-term newborn" Ineffective thermoregulation related to decreased amount of subcutaneous fat
Ineffective thermoregulation related to decreased amount of subcutaneous fat Explanation: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority.
A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication? Cold stress Intraventricular hemorrhage (IVH) Respiratory distress syndrome Retinopathy of prematurity (ROP)
Intraventricular hemorrhage (IVH) Explanation: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanelle, cyanosis, and increased head circumference.
A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication? Cold stress Intraventricular hemorrhage (IVH) Retinopathy of prematurity (ROP) Respiratory distress syndrome
Intraventricular hemorrhage (IVH) Explanation: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanelle, cyanosis, and increased head circumference.
A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication? Respiratory distress syndrome Retinopathy of prematurity (ROP) Intraventricular hemorrhage (IVH) Cold stress
Intraventricular hemorrhage (IVH) Explanation: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanelle, cyanosis, and increased head circumference.
A newborn admitted to the nursery weighs 2,000 grams. This newborn is classified as which of the following? Low birth weight High birth weight Very low birth weight Normal birth weight
Low birth weight Explanation: The classification of a low birth weight (LBW) is a newborn that weighs less than 2,500 grams (g).
The nursing students describe the infant they are caring for as weighing 2000 g. The instructor knows that effective communication among staff members suggests that what term be used to describe the infant? Very low birth weight (VLBW) Extremely low birth weight (ELBW) Large for gestational age (LGA) Appropriate for gestational age (AGA) Low birth weight (LBW)
Low birth weight (LBW) Explanation: Newborns weighing less than 2400 g but greater than 1500 g are termed low-birth-weight infants. VLBW weigh more than 1000 g but less than 1500 g. ELBW infants weigh less than 1000 g. LGA infants weigh greater than 90th percentile for their gestational age.
At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the baby's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? Rooting reflex Babinski reflex Moro reflex Stepping reflex
Moro reflex Explanation: When a baby has a brachial plexus palsy, there will be asymmetry of the Moro reflex. The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. Babinski reflex is a sign of neurologic immaturity.
At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the baby's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? Stepping reflex Babinski reflex Moro reflex Rooting reflex
Moro reflex Explanation: When a baby has a brachial plexus palsy, there will be asymmetry of the Moro reflex. The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. Babinski reflex is a sign of neurologic immaturity.
When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? Acetaminophen Morphine Aspirin Ibuprofen
Morphine Explanation: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid narcotic, is given to the client to ease the withdrawal symptoms and also gradually remove narcotics from the system. The other options do not ease withdrawal symptoms.
The nurse in the newborn nursery has used the Ballard scoring system to assess the newborn. This gestational assessment evaluation includes which of the following categories of maturity of the newborn? Cardiac and psychological Genitourinary and hearing Respiratory and vision Neuromuscular and physical
Neuromuscular and physical Explanation: The Ballard scoring system is a common gestational age assessment tool used in newborn nurseries. Gestational age assessment involves evaluation of two main categories of maturity: neuromuscular and physical maturity.
The nurse in the newborn nursery has used the Ballard scoring system to assess the newborn. This gestational assessment evaluation includes which of the following categories of maturity of the newborn? Genitourinary and hearing Respiratory and vision Cardiac and psychological Neuromuscular and physical
Neuromuscular and physical Explanation: The Ballard scoring system is a common gestational age assessment tool used in newborn nurseries. Gestational age assessment involves evaluation of two main categories of maturity: neuromuscular and physical maturity.
If the nurse suspects intraventricular hemorrhage (IVH) in a preterm newborn, which of the following would the nurse be likely to find? Restlessness, crying, irritability Redness and bruising on the scalp Tachycardia and hyperperfusion No signs or only subtle signs
No signs or only subtle signs Explanation: Generally, a preterm infant who develops IVH is asymptomatic or has very subtle signs such as a dropping hematocrit level, pallor, and poor perfusion. Although there usually are no signs or are just subtle signs, signs such as apnea, bradycardia, bulging fontanelles, cyanosis, twitching, convulsions, and increased head circumference may occur.
A neonate is diagnosed with Erb's palsy after birth. The parents are concerned about their baby's limp arm. The nurse explains the baby will be scheduled to receive what recommended treatment for this condition? Physical therapy to the joint and extremity Immobilization of the shoulder and arm Nothing but time and let nature take its course Surgery to correct the joint and muscle alignment
Physical therapy to the joint and extremity Explanation: Physical therapy to the extremity, beginning at about 1 week of age, will evaluate the extent of the injury and will help the neonate to regain function. Immobilization is the recommended treatment for a fractured clavicle. Surgery is not needed to regain function since there is no structural injury. Doing nothing will not help the neonate regain function in the extremity.
A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply. Let the newborn sleep in the same bed as the parents. Not allow anyone to smoke around the infant. Avoid using a pacifier when putting the infant to sleep. Place the infant on his or her back. Keep the infant dressed warmly at night.
Place the infant on his or her back. Not allow anyone to smoke around the infant. Explanation: Although the specific cause of SIDS cannot be explained, these interventions have been shown to decrease the incidence of the syndrome: place infant on the back to sleep; use a firm sleep surface; breastfeeding; room sharing without bed sharing; routine immunizations; consideration of using a pacifier; avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs
All of the following complications are more likely to develop in a large for gestational age (LGA) newborn as opposed to an appropriate for gestational age (AGA) newborn except: Polycythemia Shoulder dystocia Breech presentation Cesarean delivery
Polycythemia Explanation: Polycythemia is more likely to occur in a small for gestational age (SGA) newborn as a response to persistent oxygen deprivation. Cesarean delivery, breech presentation, and shoulder dystocia are all more likely to occur in an LGA infant.
All of the following complications are more likely to develop in a large for gestational age (LGA) newborn as opposed to an appropriate for gestational age (AGA) newborn except: Shoulder dystocia Cesarean delivery Polycythemia Breech presentation
Polycythemia Explanation: Polycythemia is more likely to occur in a small for gestational age (SGA) newborn as a response to persistent oxygen deprivation. Cesarean delivery, breech presentation, and shoulder dystocia are all more likely to occur in an LGA infant.
Which nursing action is required when caring for the post-term infant? temperature checks every 2 hours Serial blood glucose levels Echocardiogram at the end of pregnancy IV initiation
Serial blood glucose levels Explanation: Of the options provided, the one that is required is serial blood glucose levels. The newborn may require IV glucose infusion to stabilize glucose level. The rest of the options are on an as-needed basis.
A pregnant woman at 41 weeks' gestation is scheduled for labor induction. What does the nurse monitor after the birth of the baby? Serial blood glucose levels Surfactant levels BUN and creatinine levels AST levels
Serial blood glucose levels Explanation: The nurse should monitor serial blood glucose levels. The newborn may require intravenous glucose infusions to stabilize the glucose level.
Which preventable cause of intrauterine growth restriction (IUGR) is most common? Hypertension Alcohol use Smoking Gestational diabetes
Smoking Explanation: Smoking is the most common preventable cause of IUGR. Hypertension and gestational diabetes are not entirely preventable. Alcohol use is not as common as smoking.
Which nursing actions limit overstimulation of the preterm infant? Select all that apply. Frequently open the isolette portholes. Keep lights low in the nursery. Tap on the isolette before opening the door. Speak softly to the infant. Coordinate nursing care.
Speak softly to the infant. Keep lights low in the nursery. Coordinate nursing care. Explanation: It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions. Tapping and opening the isolette portholes can startle the infant.
The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort? Swaddle and decrease stimulation Provide 1 ounce of formula Administer benzodiazepines Promote parental bonding
Swaddle and decrease stimulation Explanation: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.
The registered nurse (RN) is determining a newborn's gestational age. What tool would be best used to evaluate this? The Apgar scoring system. The Lamaze scoring system. The Ballard scoring system. The intrauterine scoring system.
The Ballard scoring system. Explanation: The Ballard scoring system is a common gestational age assessment tool used in newborn nurseries. Gestational age assessment involves evaluation of two main categories of maturity: neuromuscular and physical maturity.
The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate? The infant was born at term but at a low birth weight and small for gestational age. The infant was a preterm, very low birth weight and small for gestational age. The infant was a preterm, low birth weight and small for gestational age neonate. The infant was born at term but a very low birth weight and small for gestational age.
The infant was a preterm, low birth weight and small for gestational age neonate. Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2,500 g) and small for gestational age at the 8th percentile (under the 10th percentile). The other documentations are not accurate.
In doing the Ballard assessment of gestational age, which of the following is done to assess what is called the scarf sign? It is the measurement of the wrist angle with flexion toward the forearm until resistance is met. It is the measurement of the knee angle when the thigh is flexed and the lower leg extended until resistance is met. The infant's foot is moved to as close to the head as possible without forcing the foot. The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met.
The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met. Explanation: Scarf sign (arm pulled gently in front of and across top portion of body until resistance is met) is one of the six categories that determine neuromuscular maturity in a newborn.
The nurse is caring for a newborn who is large for gestational age. Which characteristics are documented as a contributing factor? Select all that apply. The mother has had previous large for gestational age neonates. Both parents are of a larger stature and size. The father is obese but mother is of normal weight. The neonate is a female. The mother is a poorly controlled diabetic.
The mother has had previous large for gestational age neonates. The mother is a poorly controlled diabetic. Both parents are of a larger stature and size. Explanation: Common contributing factors for a large for gestational age neonate are the mother having a history of previous large for gestational age neonates; the mother having a high glucose level due to a poorly controlled diabetic status; and genetic characteristics of the parents being of a larger size and stature. A larger-sized infant is more correlated with an obese mother than obese father. Males are more likely to be large for gestational age.
The nurse is caring for a newborn who is large for gestational age. Which characteristics are documented as a contributing factor? Select all that apply. The mother has had previous large for gestational age neonates. The neonate is a female. The mother is a poorly controlled diabetic. Both parents are of a larger stature and size. The father is obese but mother is of normal weight.
The mother has had previous large for gestational age neonates. The mother is a poorly controlled diabetic. Both parents are of a larger stature and size. Explanation: Common contributing factors for a large for gestational age neonate are the mother having a history of previous large for gestational age neonates; the mother having a high glucose level due to a poorly controlled diabetic status; and genetic characteristics of the parents being of a larger size and stature. A larger-sized infant is more correlated with an obese mother than obese father. Males are more likely to be large for gestational age.
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? intake and output for 8 hours soft, flat anterior fontanels pink skin with noted blue extremities a sudden drop in hemocrit
a sudden drop in hemocrit Explanation: The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels, changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? soft, flat anterior fontanels pink skin with noted blue extremities a sudden drop in hemocrit intake and output for 8 hours
a sudden drop in hemocrit Explanation: The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels, changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.
The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: has facial deformities. weighed above average when born. cries when touched. sleeps for long periods of time.
cries when touched. Explanation: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born.
When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? between 2 and 4 days of life during the first 24 hours of life after 5 days postpartum often with formula-fed babies
during the first 24 hours of life Explanation: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies.
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? newborn who is type A, father who is type O newborn who is type O, father who is type A newborn who is type A, mother who is type O newborn who is type O, mother who is type O
newborn who is type A, mother who is type O Explanation: Hemolytic disease of the newborn may develop when a mother and the unborn fetus have different blood types. The disease occurs when the immune system of the mother sees the fetuss red blood cells as foreign. Antibodies then develop against the fetus's red blood cells. These antibodies attack the red blood cells beginning at birth, cause them to break down too early. There is more than one way in which the fetus's blood type may not match the mother's. Commonly, it result of ABO incompatibility. It also occurs with Rh factor incompatibility. Of the options provided. the newborn with type A and the mother with type O will result in hemolytic disease of the newborn.
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? newborn who is type A, mother who is type O newborn who is type O, mother who is type O newborn who is type A, father who is type O newborn who is type O, father who is type A
newborn who is type A, mother who is type O Explanation: Hemolytic disease of the newborn may develop when a mother and the unborn fetus have different blood types. The disease occurs when the immune system of the mother sees the fetuss red blood cells as foreign. Antibodies then develop against the fetus's red blood cells. These antibodies attack the red blood cells beginning at birth, cause them to break down too early. There is more than one way in which the fetus's blood type may not match the mother's. Commonly, it result of ABO incompatibility. It also occurs with Rh factor incompatibility. Of the options provided. the newborn with type A and the mother with type O will result in hemolytic disease of the newborn.
The nurse is providing care to a newborn with severe meconium aspiration syndrome (MAS). The nurse is reviewing the newborn's diagnostic test results. Which finding would the nurse expect? increased PaO2 elevated blood pH patchy, fluffy infiltrates on chest X-ray vocal cords negative for meconium
patchy, fluffy infiltrates on chest X-ray Explanation: Chest X-rays show patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis. ABG analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Direct visualization of the vocal cords for meconium staining using an appropriate size laryngoscope is needed.
