Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders

A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate?

"The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days." Assessment indicates that the newborn has caput succedaneum. This is soft tissue swelling caused by edema of the head against the dilating cervix during the birth process. In caput succedaneum, swelling is not limited by suture lines; it extends across the midline and is associated with head molding. It does not usually cause complications other than a misshapen head and usually resolves over the first few days without treatment. Cephalohematoma is the subperiosteal collection of blood secondary to the rupture of blood vessels between the skull and periosteum. Suture lines delineate its extent and it is usually located on one side, over the parietal bone. Cephalohematoma resolves gradually over 2 to 3 weeks without treatment. Subarachnoid hemorrhage (one of the most common types of intracranial trauma) may be due to hypoxia/ischemia, variations in blood pressure, and the pressure exerted on the head during labor. Bleeding is of venous origin, and underlying contusions also may occur. Subarachnoid hemorrhage requires minimal handling to reduce stress. Subdural hemorrhage (hematomas) involves tears of the major veins or venous sinuses overlying the cerebral hemispheres or cerebellum. Increased pressure on the blood vessels inside the skull leads to tears. Subdural hematoma requires aspiration; can be life-threatening if it is in an inaccessible location and cannot be aspirated.

A nurse notices a mother in the NICU crying next to her premature 25-week-old neonate. What is the most appropriate response by the nurse?

"This situation must be difficult for you. Can you tell me what concerns you have right now?" The nurse should allow clients to share and reflect feelings by verbalizing how they feel. The nurse should not suggest a chaplain without knowing clients' religious beliefs, give false hope to clients, or ask clients to decide why they have certain feelings.

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." 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 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 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.

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?

Appropriate for gestational age 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 34 and 37 weeks 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. 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).

A nurse makes a home visit to a new mother and her 5-day-old newborn. Assessment of the newborn reveals slight yellowing of the skin on the face and forehead and slowed skin turgor. The mother tells the nurse that she's been having trouble breastfeeding the newborn. "My baby's been feeding about every 4 to 5 hours." Additional assessment reveals about 3 wet diapers per day and 1 to 2 stools per day. Which action by the nurse would be the priority?

Call the provider to obtain a prescription for a bilirubin level. The assessment findings and report from the mother suggest late-onset breastfeeding jaundice. The nurse should report the findings to the provider and obtain a prescription for a bilirubin level. Once the results are obtained, then the decision for home phototherapy can be made. Although it would be helpful to evaluate the mother's breastfeeding technique to promote enhanced breastfeeding, the priority is to confirm hyperbilirubinemia and institute measures to lower the bilirubin level. Measuring the newborn's abdominal girth would be unnecessary.

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin?

Chlamydia trachomatis 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 type 1 and HIV.

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?

Creases covering two-thirds of the anterior foot 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.

What intervention can the nurse provide to reduce pain and stress in the preterm infant?

Create minimal stimulation and reduce procedures that cause pain. Minimal stimulation is a necessary precaution to minimize pain and stress. The nurse should reduce procedures that cause crying, such as routine suctioning. He or she should avoid painful procedures and disturbances when possible. The nurse should administer narcotics, as ordered, to treat pain when avoidance is not possible. Additionally, he or she should control the noise level in the environment and provide developmental care and positioning.

The nurse is instructing a diabetic mother on the complications associated with uncontrolled blood glucose levels. Which complication is most concerning?

Delayed lung maturity 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 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?

Gestational age Gestational age is the length of time between fertilization of the egg and birth.

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?

Ineffective thermoregulation related to decreased amount of subcutaneous fat 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.

Why does breathing require greater effort for the preterm newborn?

Lack of surfactant 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.

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?

Moro reflex 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?

Morphine 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.

What would the nurse suspect in a premature newborn who has difficulty feeding and maintaining a stable temperature and is vomiting bile?

Necrotizing enterocolitis Necrotizing enterocolitis is a disease that is characterized by inflammation in the bowels. It is generally idiopathic and results in difficulty feeding and maintaining thermoregulation, as well as vomiting of bile.

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 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.

Prophylactic antibiotics may prevent development of pneumonia.

Posture Arm recoil Scarf sign Heel to ear movement Square window The category of assessment is neuromuscular maturity. All of the categories are included on the Ballard scoring system except for neonatal reflexes. Reflexes are screened separately.

Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs?

Provide a dark, quiet environment 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:

Scarf sign. 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 nursing action is required when caring for the post-term infant?

Serial blood glucose levels 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.

Which preventable cause of intrauterine growth restriction (IUGR) is most common?

Smoking 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.

Speak softly to the infant. Keep lights low in the nursery. Coordinate nursing care. 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 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. 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?

The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met. 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 most correct to assess for transient tachypnea of the newborn (TTN) in which neonate?

The neonate delivered by cesarean section 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.

The nurse is caring for a preterm neonate and has chosen the following goal: improvement of the neonate's respiratory function. Which expected outcome is most appropriate for the first week?

The neonate will not use accessory muscles when breathing. The goal most appropriate for the first week of life is to not use accessory muscles or grunting when breathing. This signifies an improvement in the respiratory status. A 99% oxygen saturation rate is too high for the neonate. Maintaining the temperature and sleeping without apnea are acceptable goals but not most reflective of improvement in the respiratory status.

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification?

The skin is jaundiced. 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. This neonate exhibits pathologic jaundice, which needs to be reported immediately. Milia is common on the newborn. It is appropriate for the newborn to sleep for most of the day and eat a couple ounces of formula.

Which of the following is not true regarding preterm birth?

The use of tocolytics has reduced the overall number of preterm births. The use of tocolytics (drugs with the primary purpose of relaxing the uterus and therefore decreasing contractions) has improved outcomes, but has not affected the occurrence of preterm birth.

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?

a sudden drop in hematocrit 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.

After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia?

antibiotics Prophylactic antibiotics may prevent development of pneumonia.

The nurse is providing care to a newborn with macrosomia who has sustained a midclavicular fracture. When reviewing the mother's labor and birth record, the nurse notes the following information: Breech birth Amniotomy APGAR score: 7 at 1 minute; 8 at 5 minutes Oxytocin augmentation Which information would the nurse correlate with the newborn's current injury?

breech birth Midclavicular fractions most often occur during breech births or shoulder dystocia in newborns with macrosomia. Amniotomy or oxytocin augmentation are not associated with this type of fracture. The newborn's APGAR scores indicate a healthy newborn and are unrelated to the birth injury.

A nurse is caring for a newborn who was diagnosed with an imperforate anus. Assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. Which action by the nurse would be appropriate?

clear the airway The newborn is showing signs of esophageal atresia based on the assessment. The nurse would clear the airway and notify the health care provider. Newborns with imperforate anus often have other anomalies including esophageal atresia. With this condition, a gastric tube cannot be inserted beyond a certain point because the esophagus ends in a blind pouch. Therefore gavage feedings would be inappropriate. Although the newborn has copious mucus, suctioning the throat and endotracheal intubation are not warranted. Excess secretions should be removed with a bulb syringe.

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. 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?

during the first 24 hours of life 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 preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH) Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full (or bulging) fontanel, cyanosis, and increased head circumference.

A newborn is diagnosed with a birth injury secondary to shoulder dystocia. Assessment of the newborn's reflexes reveals the following: Positive Moro reflex Negative grasp reflex Negative radial reflex Positive bicep reflex The nurse suspects an upper brachial plexus injury based on which finding?

negative radial reflex With a left upper brachial plexus injury, also known as Erb palsy, the involved extremity usually presents adducted, prone, and internally rotated; shoulder movement is absent; Moro, bicep, and radial reflexes are absent, but the grasp reflex is usually present. Klumpke palsy, a lower brachial plexus injury, is manifested by weakness in the hand and wrist and an absent grasp reflex.

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 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 fetus's 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, causing 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 is the 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?

patchy, fluffy infiltrates on chest X-ray 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.

A nurse is providing care to a newborn who is 10 hours old. The parent suddenly calls the nurse into the room because the newborn is having problems. On entering the room, the nurse observes the newborn to be cyanotic and tachypneic with grunting. Sternal retractions are noted. The nurse auscultates the newborn's heart and notes a harsh systolic ejection murmur. The nurse immediately notifies the provider based on the nurse's suspicion that this newborn is experiencing which condition?

persistent pulmonary hypertension of the newborn The assessment findings support the development of persistent pulmonary hypertension of the newborn. A newborn with persistent pulmonary hypertension demonstrates tachypnea within 12 hours after birth along with marked cyanosis, grunting, respiratory distress with tachypnea, and retractions, a systolic ejection harsh sound (tricuspid insufficiency murmur) and hypotension resulting from both heart failure and persistent hypoxemia. Signs of transient tachypnea occur within the first few hours of birth and include tachypnea with rates as high as 100 to 140 breaths/minute, expiratory grunting, retractions, labored breathing, nasal flaring, mild cyanosis, hyperextension or a barrel-shaped chest and slightly diminished breath sounds secondary to reduced air entry. The newborn with respiratory distress syndrome usually demonstrates signs at birth or within a few hours of birth, such as for expiratory grunting, shallow breathing, nasal flaring, chest wall retractions, seesaw respirations, and generalized cyanosis. Meconium aspiration syndrome is manifested by barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis.

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature?

surfactant Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.