Chapter 23: Nursing Care of the Newborn with Special Needs

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following? Hyperbilirubinemia Hypothermia Polycythemia Hypoglycemia

Hypothermia Subcutaneous and brown fat stores may be used by the stressed fetus to survive in utero and thus will not be available to provide extrauterine warmth. Excessive red blood cell breakdown is responsible for hyperbilirubinemia, not the breakdown of brown fat stores. Polycythemia is caused by a buildup of red blood cells in response to a hypoxic state in utero; it is not linked to loss of subcutaneous and brown fat stores. Glycogen stores are used for survival in an environment with depleted glycogen and are unrelated to brown fat stores.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? postterm preterm SGA LGA

postterm Explanation: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence? hypoglycemia polycythemia meconium aspiration asphyxia

hypoglycemia Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding? sudden high-pitched cry fussiness increased muscle tone lack of body posturing

lack of body posturing Explanation: The newborn may be in pain if the following are exhibited: sudden high-pitched cry; facial grimace with furrowing of brown and quivering chin; increased muscle tone; oxygen desaturation; body posturing, such as squirming, kicking, and arching; limb withdrawal and thrashing movements; increase in heart rate, blood pressure, pulse, and respirations; fussiness and irritability

Which finding is indicative of hypothermia of the preterm neonate? regular respirations oxygen saturation of 95% pink skin nasal flaring

nasal flaring Explanation: Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 100 mg/100 ml whole blood 80 mg/100 ml whole blood 45 mg/100 ml whole blood 30 mg/100 ml whole blood

45 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.

After fetal distress was noted on the monitor, a postterm newborn was delivered via a difficult vacuum extraction. The newborn had low Apgar scores and had to be resuscitated before being transferred to the nursery. Once admitted, the nurse observed the following behaviors: jitteriness, tremors, hypotonia, lethargy, and rapid respirations. a. What might these behaviors indicate?

These behaviors are clinical signs of hypoglycemia, which is common in a postterm infant after a difficult birth; glycogen stores are depleted secondary to chronic placental insufficiency.

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response? "Your baby is more sensitive to the pain than adults are." "Premature babies like yours will not feel pain yet." "The pain receptors in the brain are not sensitive to it like adults are." "Your baby is just more irritable from the procedures."

"Your baby is more sensitive to the pain than adults are." Explanation: The newborn pain prevention and management guidelines indicate that newborn pain frequently goes unrecognized and undertreated. Pain assessment is an essential activity prior to pain management. Newborns experience pain, and analgesics should be given. A procedure considered painful for an adult should also be considered painful for a newborn. Developmental maturity and health status must be considered when assessing for pain in newborns. Newborns may be more sensitive to pain than adults. Pain behavior is frequently mistaken for irritability and agitation.

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response? "Your infant's cardiovascular system is not developed yet in order to sustain respiration." "Most preterm infants require additional oxygen through ventilation to sustain respiration." "Premature infants have a respiratory system that takes time to adjust to extrauterine life." "Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Explanation: Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 ml/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many milliliters (ml) should the nurse administer? Record your answer using one decimal place.

0.3 Explanation: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and ventilation.epinephrine: 1:10,000 concentration0.1 to 0.3 mL/kg IV3000 grams = 3 kg3 kg x 0.1 mL/kg = 0.3 mL

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention? 40 mg/dl (2.25 mmol/l) 50 mg/dl (2.77 mmol/l) 30 mg/dl (1.67 mmol/l) 60 mg/dl (3.33 mmol/l)

30 mg/dl (1.67 mmol/l) Explanation: Hypoglycemia in a neonate is defined as blood glucose value typically below 35 to 45 mg/dl (1.94 to 2.50 mmol/l). The American Academy of Pediatrics recommends intervening for a blood glucose less than 40 mg/dl (2.25 mmol/l) in the first 4 hours of life, and less than 45 mg/dl (mmol/l) at ages 4 hours to 24 hours.

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation? Continue bag and mask ventilation only. Continue bag and mask ventilation and cardiac compressions. Continue cardiac compressions only. Allow the infant a chance to stabilize without further intervention.

Continue bag and mask ventilation only. Explanation: The infant is exhibiting respiratory distress and needs continued bag and mask resuscitation. The heart rate is greater than 60 bpm, so cardiac compressions are not needed.

A newborn is determined to have an injury to the brachial plexus. Which condition should the nurse include when preparing a teaching session for the parents? bulbar palsy Erb palsy cerebral palsy Bell palsy

Erb palsy Explanation: Injury to the brachial plexus results in Erb palsy or a paralysis of the arm caused by injury to the upper group of the arm's main nerves. Bulbar palsy is due to a lesion that impairs function of cranial nerves IX, X, XI, and XII. It is not birth related. Bell palsy causes temporary facial paralysis, sometimes seen when forceps are used to assist the birth. Cerebral palsy is caused by hypoxia brain injury.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia? temperature instability tea-colored urine seizures feeble sucking

Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

SGA and LGA newborns have an excessive number of red blood cells related to: Hypoxia Hypoglycemia Hypocalcemia Hypothermia

Hypoxia The fetus's body, in an attempt to compensate for the low oxygen level, produces more red blood cells to carry the limited amount of oxygen available. Thus, polycythemia will be present at birth in a fetus experiencing hypoxia in utero. Hypoglycemia is typically caused by inadequate stores of glycogen and overuse while living in a hostile environment. Low serum calcium levels are associated with perinatal asphyxia and not an increase in red blood cells. Hypothermia is associated with a decrease in body fat, particularly brown fat stores, and is not linked to increased production of red blood cells.

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dl (2.22 mmol/L). Which nursing action is the priority? Monitor the infant at feedings. Initiate early oral feedings. Initiate daily infant weights. Ensure feedings are on demand.

Initiate early oral feedings. Explanation: Metabolic needs are increased for catch-up growth in an infant who is small for gestational age. The nurse will initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury because the brain needs glucose continuously as a primary source of energy. An infant stressed at birth uses up available glucose stores quickly, with resulting hypoglycemia. A plasma glucose concentration lower than 60 mg/dl (3.33 mmol/L) necessitates frequent oral feedings. With the loss of the placenta at birth, the infant now must assume control of glucose homeostasis through oral feedings. The other actions are not a priority at this time.

Which of the following concepts would the nurse incorporate into the plan of care when assessing pain in a newborn with special needs? Newborns experience pain primarily with surgical procedures. Preterm newborns in the NICU are at least risk for pain. Pain assessment needs to be comprehensive and frequent. A newborn's facial expression is the primary indicator of pain.

Pain assessment needs to be comprehensive and frequent. Newborns feel pain and require the same level of pain assessment and pain management as adults. Pain assessment, which is comprehensive, involves observations of changes in vital signs, behavior, facial expression, and body movement. It is considered the "fifth vital sign" and should be checked as frequently as the other four signs. All newborns experience pain, not just newborns undergoing surgical procedures. Preterm newborns have an increased risk of pain because they are subjected to repeat procedures and exposed to noxious stimuli.

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate? The infant was a preterm, 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 born at term but at a very low birth weight and small-for-gestational-age The infant was a preterm, very-low-birthweight and small-for-gestational-age

The infant was a preterm, low-birth-weight and small-for-gestational-age Explanation: Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. What findings would correlate with this suspicion? Select all that apply. The newborn has green staining of the fingernails. The umbilical cord is stained bright red. The newborn has labored abdominal respirations. The newborn makes bearing down movements. The anterior fontanels (fontanelles) are sunken at birth. Green amniotic fluid is present at birth.

The newborn has green staining of the fingernails. The newborn makes bearing down movements. Green amniotic fluid is present at birth. The newborn has labored abdominal respirations. Meconium aspiration is evidenced by the presence of green amniotic fluid with rupture of membranes during labor. There is green staining of the umbilical cord or fingernails. The newborn struggles with breathing by making respiratory efforts and bearing down with abdominal muscles to expel meconium. Fontanel (fontanelle) assessment does not apply at this time. Bright red staining on the umbilical cord at birth is normal.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother? With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. The newborn aspirated meconium, causing the wasted appearance. A postterm newborn has begun to break down red blood cells more quickly. The newborn was exposed to an infection while in utero.

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

What action by the nurse provides the neonate with sensory stimulation of a human face? assisting the mother to position the infant in an en face position encouraging the mother to view the baby through the isolette dome having mothers look at the infant through the isolette's porthole teaching parents to maintain a distance of 18 inches (7 cm) from the baby's face

assisting the mother to position the infant in an en face position Explanation: To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care? clustering care and activities giving a bath administering medications holding the infant

clustering care and activities Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? evaporation convection radiation conduction

conduction Explanation: A conduction heat loss results from direct contact with an object that is cooler.

Which condition may cause intrauterine asphyxia? Select all that apply. cord compression placental abruption (abruptio placentae) intrauterine growth restriction (IUGR) gestational diabetes group B streptococcus (GBS) infection

cord compression placental abruption (abruptio placentae) intrauterine growth restriction (IUGR) Explanation: Conditions such as cord compression, placental abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor.

A premature neonate born at 36 weeks' gestation is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment finding(s) will the neonate demonstrate? Select all that apply. increased serum bilirubin levels clay-colored stools tea-colored urine cyanosis congenital dermal melanocytosis (slate gray nevi)

increased serum bilirubin levels clay-colored stools tea-colored urine Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are not associated with newborn jaundice.

An infant who is diagnosed with meconium aspiration displays which symptom? intercostal and substernal retractions pink skin respirations of 45 no heart murmur

intercostal and substernal retractions Explanation: Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? meconium aspiration in utero or at birth seizures, respiratory distress, cyanosis, and shrill cry yellow appearance of the newborn's skin tremors, irritability, and high-pitched cry

meconium aspiration in utero or at birth Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis? meconium-stained skin and fingernails abundant vernix caseosa and lanugo Wharton's jelly few creases on soles

meconium-stained skin and fingernails Explanation: Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanugo; and meconium-stained skin and fingernails.

Which nursing interventions promote healthy development of the preterm neonate? Select all that apply. nesting nonnutritive sucking quiet hours covering the incubator supine sleep position

nesting nonnutritive sucking quiet hours covering the incubator Explanation: To promote development, the nurse provides nonnutritive sucking and quiet hours, covers the incubator to minimize external stimulation, and positions the infant on the side with extremities flexed and supported or nested.

The nurse needs to conduct a procedure on a preterm newborn. Which measure(s) will the nurse use to help reduce pain? Select all that apply. removing tape quickly from the skin increasing the volume on device alarms offering a pacifier prior to a procedure swaddling the newborn closely encouraging skin-to-skin (kangaroo) care during procedures

offering a pacifier prior to a procedure swaddling the newborn closely encouraging skin-to-skin (kangaroo) care during procedures Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries; using gentle handling, rocking, caressing, and cuddling; encouraging skin-to-skin (kangaroo) care during procedures; and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms.

A preterm infant of 32 weeks' gestation is admitted from the birth suite to the neonatal intensive care unit with symptoms of respiratory distress. What would the nurse expect to see during assessments? Select all that apply. pH 7 PaCO2 54 mm Hg heart rate 110 bpm respiratory rate 34 breaths/min temperature 99.5° F (37.5° C) PaO2 35

pH 7 PaCO2 54 mm Hg PaO2 35 Explanation: The preterm newborn develops atelectasis quickly without alveoli stabilization leading to RDS with hypoxemia, respiratory acidosis, and hypercarbia. This change in the newborn's biochemical environment allows fetal circulation patterns to persist with bradycardia, tachypnea, and hypothermia developing. Respiratory acidosis occurs when the carbon dioxide (PaCO2) is elevated above the normal range (44 mm Hg) leading to a blood pH lower than 7.35. Bradycardia is a heart rate less than 100 bpm. Respiratory rates of 30 breaths per minute are considered worrisome in the newborn. Five minutes after delivery, the PaO2 is approximately 35 to 40, and the oxygen saturation is in the mid 80s.

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings? hypercalcemia polycythemia hyponatremia hyperglycemia

polycythemia Explanation: Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).

A nurse is assisting with the resuscitation of a preterm newborn. Which assessment would help assist the team in determining that the resuscitation efforts have been successful? pink conjunctiva respiratory rate of 10 breaths per minute pulse rate of 110 beats per minute weak cry effort

pulse rate of 110 beats per minute Explanation: Resuscitation measures are continued until the newborn has a pulse above 100 bpm, a good healthy cry or good breathing efforts, and a pink tongue. This last sign indicates a good oxygen supply to the brain. Conjunctival assessment would be of no benefit. A respiratory rate of 10 breaths per minute alone does not indicate the respiratory effort.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration? bronchopulmonary dysplasia (chronic lung disease) retinopathy of prematurity diminished erythropoiesis necrotizing enterocolitis TAKE ANOTHER QUIZ

retinopathy of prematurity Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia (chronic lung disease), diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia (chronic lung disease) results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? sticky forest green soft brown seedy yellow formed green

sticky forest green Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,: the ductus arteriosus remains open. the foramen ovale closes prematurely. there are aortic valve strictures. the pulmonary artery closes.

the ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?

thick umbilical cord

For what other conditions might this newborn be at high risk?

Besides hypoglycemia, hypothermia, polycythemia, meconium aspiration, and hyperbilirubinemia are common in the postterm infant.

A 10-pound LGA newborn is brought to the nursery after a difficult vaginal birth. The nursery nurse should focus on detecting birth injuries such as ___________________.

Common birth injuries include clavicle fractures, facial palsies, and brachial plexus injuries.

What would be an appropriate intervention to manage this condition?

Obtain a venous hematocrit measurement within 4 to 6 hours after birth to validate this condition, since its manifestations are very similar to those of hypoglycemia. Hematocrit values over 65% should be brought to the health care provider's attention. Typically it is treated by a dilutional exchange transfusion.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

Radiation

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus

A common metabolic disorder present in both SGA and LGA newborns after birth is

hypoglycemia

The nurse determines a newborn is small-for-gestational-age based on which characteristics? wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores wasted appearance of extremities, gelatinous umbilical cord, and abundant subcutaneous fat stores reduced subcutaneous fat stores to buttocks, thicker umbilical cord, and smaller head compared to body normal subcutaneous fat stores, cord-like umbilical cord, and increased development to extremities

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores Explanation: The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.

An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse? "Wait outside and we will call you later." "Come on over and I will explain your infant's exam and findings." "The infant is okay, just wait until your health care provider speaks to you." "Oh yeah, the infant seems fine, you can see your infant soon."

"Come on over and I will explain your infant's exam and findings." Explanation: The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their infant. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: inspiratory stridor. expiratory grunting. expiratory wheezing. inspiratory "crowing."

expiratory grunting. Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl (1.28 mmol/L). The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? Administer dextrose intravenously. Monitor the infant's hematocrit levels closely. Administer PO glucose water immediately. Place the infant on a radiant warmer.

Administer dextrose intravenously. Explanation: The infant is demonstrating signs and symptoms of significant hypoglycemia. IV dextrose should be administered to the term newborn intravenously when the blood glucose level is less than 40 mg/dL (2.22 mmol/L), and the newborn is symptomatic for hypoglycemia. Administration of IV glucose assists in stabilizing blood glucose levels. Providing oral glucose feedings or placing the infant on a radiant warmer will not help maintain the glucose level. Monitoring the infant's hematocrit level is not a priority and not related to the problem at hand.

The obstetrics nurse has admitted a large-for-gestational-age infant, 1-hour old, for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action? Begin supervised feedings for the newborn. Return the newborn to its parents for bonding. Transfer the newborn to the neonatal intensive care unit. Recheck the newborn's blood glucose in 4 hours.

Begin supervised feedings for the newborn. Explanation: Hypoglycemia in a neonate is defined as a blood glucose value below 40 mg/dL (2.22 mmol/L). Supervised breastfeeding or formula feeding may be the initial treatment options in asymptomatic hypoglycemia. Hypoglycemia has been linked to poor neurodevelopmental outcomes, and hence aggressive screening and treatment are recommended. Monitor blood glucose levels within 30 minutes of birth, and repeat the screening every hour. Recheck levels before feedings and also immediately in any infant suspected of having or showing clinical signs of hypoglycemia.

A mother of a neonate who was born at 32 weeks' gestation is encouraged to perform skin-to-skin (kangaroo) care in the neonatal intensive care unit. What would best correlate with this suggestion? The infant will have more awake periods. There will be a decrease in episodes of apnea. Breastfeeding attempts will be enhanced. The infant will adjust better to the environment.

Breastfeeding attempts will be enhanced. Explanation: To promote nutrition in the preterm newborn the newborn will attempt nuzzling at the breast in conjunction with kangaroo care if the newborn is stable. Skin-to-skin (kangaroo) care offers the most benefits for preterm and low-birth-weight infants with increased weight gain. Preterm infants who experience kangaroo care have improved sleep patterns and breastfeeding attempts. It will not assist in preventing apnea. At 32 weeks' gestation it will not be necessary to have the infant adjust to the environment. Nutrition through breastfeeding is the priority.

What intervention would be appropriate for the nurse to initiate?

Bundle or nest the preterm newborn with warmed blankets and move the isolette away from the door to prevent heat loss by convection. Place a knitted cap on the newborn's head and monitor his temperature frequently.

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Closely monitor temperature. Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance.

Closely monitor temperature. Explanation: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with the ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.

What intervention is needed to address this newborn''s condition?

Feed the newborn as early as possible, or administer glucose/glucagon to counter the low blood glucose level. Decrease energy requirements to conserve glucose and glycogen stores. Maintain a neutral thermal environment to prevent cold stress, which can exacerbate the hypoglycemia.

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant? Dry the infant, stimulate the infant, and keep the infant warm. Dry the infant, administer blow-by oxygen, and keep the infant warm. Open the airway, initiate respirations, and dry the infant. Open the airway, suction the trachea, and administer oxygen.

Dry the infant, stimulate the infant, and keep the infant warm. Explanation: Dry the infant to prevent evaporative heat loss. Stimulate the infant by rubbing the side of the back to stimulate respiratory effort. Provide the thermal-neutral environment to prevent cold stress, which can cause respiratory distress. Until the infant's respiratory effort is stimulated and established, blow-by oxygen is not effective in establishing regular respirations.

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate? Sheltering the parents from the bad news Making all the decisions regarding care Encouraging them to participate in the newborn's care Leaving them by themselves to allow time to grieve

Encouraging them to participate in the newborn's care The parents need to validate the experience of loss. The best way to do this is to encourage them to participate in their newborn's care so that the grieving process can take place. Avoiding the experience of loss inhibits the grieving process. Avoidance prolongs the experience of loss and does not allow the parents to vent their feelings so that they can progress through their grief. It is not the nurse's responsibility, nor is it healthy for the family, to take over decisions for a family. Family members need to support each other and need to decide what is best for their situation. Leaving the family alone can be viewed as abandonment; privacy is important, but leaving them totally alone is not therapeutic.

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? Focus on monitoring and maintaining blood glucose levels. Check blood glucose within 2 hours of birth by reagent test strip. Repeat screening every 2 to 3 hours or before feeds. Focus on decreasing blood viscosity by increasing fluid volume.

Focus on decreasing blood viscosity by increasing fluid volume. Explanation: The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.

In assessing a preterm newborn, which of the following findings would be of greatest concern? Milia over the bridge of the nose Thin transparent skin Poor muscle tone Heart murmur

Heart murmur When a newborn is born too soon, fetal circulation may persist into extrauterine life. The ductus arteriosus and foramen ovale may remain open if pulmonary vascular resistance remains high and oxygen levels remain low. This would be manifested by a heart murmur.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. Increase the infant's hydration. Stop breastfeeding until jaundice resolves. Offer early feedings. Administer vitamin supplements. Initiate phototherapy.

Increase the infant's hydration. Offer early feedings. Initiate phototherapy. Explanation: Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation? Infant is crying. Infant is quiet. Infant is kicking feet. Infant has hand in mouth.

Infant has hand in mouth. Explanation: Self-regulation is a form of self-soothing for an infant, such as sucking on hands or putting hand to mouth.

Evidence-based practice refers to the use of which of the following to validate your practice? Research findings Written guidelines Traditional practices Institutional policies

Research findings Research validates evidence-based practice.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? Deep inspiration Expiratory lag Sternal retraction Inspiratory grunt

Sternal retraction Explanation: The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

A term SGA newborn weighing 4 pounds was brought to the nursery for admission a short time after birth. The labor and birth nurse reports the mother was a heavy smoker and a cocaine addict and experienced physical abuse throughout her pregnancy. After stabilizing the newborn and correcting the hypoglycemia with oral feedings, the nurse observes the following: acrocyanosis, ruddy color, poor circulation to the extremities, tachypnea, and irritability. a. What complication might this SGA newborn be manifesting?

The signs indicate polycythemia, which is common in SGA infants.

A preterm newborn was born at 35 weeks following an abruptio placenta due to a car accident. He was transported to the NICU at a nearby regional medical center. After being stabilized, he was placed in an isolette close to the door and placed on a cardiac monitor. A short time later, the nurse notices that he is cool to the touch and lethargic, has a weak cry, and has an axillary temperature of 36° C. a. What might have contributed to this newborn''s hypothermic condition?

The simple fact that the newborn was premature predisposes him to thermal instability because of his larger surface-to-weight ratio, immature muscle tone and decreased muscular activity to generate heat, diminished stores of subcutaneous and brown fat, and poor nutritional intake, which makes him unable to meet energy requirements for growth and development. In addition, placing the isolette close to the door might produce cold drafts, causing hypothermia.

What transfer mechanism may have been a factor?

This preterm newborn could experience loss of heat by convection (heat transfer via air currents).

Which newborn would be a priority for the nurse to monitor for thermal regulation difficulties? a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly a preterm newborn who is active, rooting, and has a lusty cry a preterm newborn naked with the mother in skin-to-skin (kangaroo) care a term newborn rooming in with its mother and breastfeeding

a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly Explanation: A preterm newborn who is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. The other newborns are at risk but not as the priority.

What is a typical feature of a small-for-gestational-age (SGA) newborn that differentiates it from a preterm baby with a low-birth-weight? decreased muscle mass face is angular and pinched decreased body temperature ability to tolerate early oral feeding

ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small-for-gestational-age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature, and an angular and pinched face are features common to both an SGA baby and a preterm baby.

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of: aging placenta. hypoxia from cord compression. loss of subcutaneous fat. increased production of red blood cells.

aging placenta. Explanation: Complications associated with a postterm newborn include perinatal asphyxia (caused by placental aging or oligohydramnios/decreased amniotic fluid); hypoglycemia (caused by acute episodes of hypoxia related to cord compression, which exhausts carbohydrate reserves); hypothermia (caused by loss of subcutaneous fat); and polycythemia (caused by an increased production of red blood cells to compensate for a reduced oxygen environment).

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? an infant whose labor began with ruptured membranes an infant who had difficulty establishing respirations at birth an infant who has marked acrocyanosis of his hands and feet an infant whose mother craved chocolate during pregnancy

an infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess? fontanels (fontanelles) skin turgor urinary output fluid intake

fontanels (fontanelles) Explanation: When assessing the fluid status of a preterm newborn, the nurse palpates the fontanels (fontanelles). Sunken fontanels (fontanelles) suggest dehydration; bulging fontanels (fontanelles) suggest overhydration.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. diabetes postdates gestation alcohol use prepregnancy obesity renal infection

diabetes postdates gestation prepregnancy obesity Explanation: Diabetes, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn being large for gestational age.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

expiratory grunting nasal flaring retractions tachypnea

How does the nurse position the infant experiencing respiratory difficulty? on the back with the head elevated 15 degrees on the right side with the head lower than the body on the stomach with the head lowered 30 degrees and head turned to the side on the left side with the head elevated 45 degrees

on the back with the head elevated 15 degrees Explanation: Positioning the infant on the back allows bilateral lung expansion. Elevating the head 15 degrees enhances movement of the diaphragm. Positioning the infant on the side or on the stomach restricts lung expansion.

A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.

placing the infant in an upright position not suctioning the airway

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration? bronchopulmonary dysplasia (chronic lung disease) retinopathy of prematurity diminished erythropoiesis necrotizing enterocolitis

retinopathy of prematurity Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia (chronic lung disease), diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia (chronic lung disease) results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?

rocking and massaging

The nurse documents that a newborn is postterm based on the understanding that he was born after: 38 weeks' gestation 40 weeks' gestation 42 weeks' gestation 44 weeks' gestation

42 weeks' gestation A postterm infant is one born after the 42nd week of gestation. Birth between 38 and 41 weeks is considered within a normal range for a term newborn. A gestation of 44 weeks would be considered extremely long if the dates were calculated correctly.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 30 mg/100 ml whole blood 45 mg/100 ml whole blood 80 mg/100 ml whole blood 100 mg/100 ml whole blood

45 mg/100 ml whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? 20th 9th 5th 95th

20th Explanation: Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement? "Late preterm infant complications are considered minor compared to those of preterm infants." "Late preterm infants are more mature and able to cope as well as full-term infants." "Late preterm infants have fewer clinical problems leading to shorter hospital stays." "Late preterm infants may have more clinical problems compared with full-term infants."

"Late preterm infants may have more clinical problems compared with full-term infants." Explanation: The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing preterm infants and require similar management. Late preterm infants have more clinical problems, longer lengths of stay, higher costs when compared with full-term infants, and increased mortalities.

A newborn is returned to the observational nursery demonstrating signs of cold stress after a prolonged bath. Which action would be a priority for the nurse? Perform a neurological assessment. Assess blood sugar level. Request arterial blood gases. Assess feeding patterns.

Assess blood sugar level. Explanation: For a client with hypothermia, a nurse would observe for clinical signs of cold stress, such as hypoglycemia. Hypoglycemia occurs due to depleted glycogen stores from the cold stress. A neurological assessment would not be a priority nor would an assessment of feeding patterns. ABG assessment would be warranted if RDS was to become a problem. At this time a blood sugar assessment is the priority.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention? Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Administration of IV epinephrine, as prescribed Transfer to a transitional or high-risk nursery for continuous cardiac surveillance Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. Handle the newborn as much as possible. Give the newborn a warm bath immediately. Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Discourage contact with parents to maintain asepsis.

Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

What factors may have contributed to this complication?

In SGA infants, polycythemia is thought to be secondary to chronic hypoxia in utero, with resulting erythropoietin production. Complications of polycythemia are related to the increased viscosity of blood, which interferes with organ circulation.

The nurse is providing care to several newborns with variations in gestational age and birthweight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply. Keeping the handling of the newborn to a minimum Maintaining a neutral thermal environment Decreasing environmental stimuli Initiating early oral feedings Using thermal warmers in all cribs

Keeping the handling of the newborn to a minimum Maintaining a neutral thermal environment Decreasing environmental stimuli Minimal handling, maintaining a neutral thermal environment, and decreasing environmental stimuli are important measures to conserve energy in newborns with variations in birth weight and gestational age. Feeding and digestion will increase energy demands. Thermal warmers may produce hypothermia and thus increase energy demands. Preventing parents from visiting their newborn is not a plan to reduce energy expenditure and could increase stress for both parents and newborn.

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next? Ventilate at a rate of 40 to 60 breaths per minute. Suction the mouth then the nose. Suction the nose then the mouth. Give 3 compressions with 1 breath every 3 seconds.

Suction the mouth then the nose. Explanation: ABCDs of newborn resuscitation include: airway maintenance by placing infant's head in "sniffing" position; suction the mouth, then the nose; suction the trachea if meconium-stained and newborn is NOT vigorous (strong respiratory effort, good muscle tone, and heart rate 100 bpm). Breathing is assisted through the use of positive-pressure ventilation (PPV) for apnea, or pulse 100 bpm. The nurse should ventilate at rate of 40 to 60 breaths/minute. Listen for raising heart rate and audible breath sounds. Look for slight chest movement with each breath. Use carbon dioxide detector after intubation. The nurse should use circulation assistance through compressions if heart rate is 60 after 30 seconds of effective PPV. Give 3 compressions: 1 breath every 2 seconds. Compress one third of the anterior-posterior diameter of the chest.

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts? above 90th percentile above 95th percentile above 85th percentile above 80th percentile TAKE ANOTHER QUIZ

above 90th percentile Explanation: A newborn whose weight is above the 90th percentile on growth charts is defined as large-for-gestational-age.

A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess? head larger than body round flushed face brown lanugo body hair protuberant abdomen

head larger than body Explanation: A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large-for-gestational-age (LGA) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body.

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? assists with ciliary body maturation in the upper airways helps maintain a rhythmic breathing pattern promotes clearing of mucus from the respiratory tract helps the lungs remain expanded after the initiation of breathing

helps the lungs remain expanded after the initiation of breathing Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant has not been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.

What is a consequence of hypothermia in a newborn? respirations of 46 heart rate of 126 holds breath 25 seconds skin pink and warm

holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process? stained umbilical cord and skin meconium stained fluids followed by tachypnea bluish skin discoloration listlessness or lethargy

meconium stained fluids followed by tachypnea Explanation: Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.