Chapter 32:Birth-Related Stressors
The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected?
"I've been sleeping very well since I had the baby."
Which nursing intervention is appropriate in the management of the preterm infant with hypothermia?
*Initiate efforts to maintain the newborn in a neutral thermal environment. *Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.
When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate?
1)Hypoxia 2)Metabolic acidosis 3)Massive atelectasis 4)Pulmonary edema
Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn?
1)Nonreassuring fetal heart rate pattern/sustained bradycardia 2)History of meconium in amniotic fluid 3)Prematurity 4)Significant intrapartum bleeding
Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement?
1)Obtain skin cultures. 2)Evaluate bilirubin levels. 3)Administer oxygen as ordered. 4)Observe for signs of hypoglycemia.
Which of the following are considered risk factors for development of severe hyperbilirubinemia?
1)Previous sibling received phototherapy 2)Exclusive breastfeeding 3)Infection
The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect?
Appearance of jaundice symptoms after 24 hours of life Yellowish coloration of the sclera of the eyes
A newborn is receiving phototherapy. Which intervention by the nurse would be most important?
Assessment of hydration status
The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?
Axillary temperature 99.7degreesF
The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?
Begin phototherapy
A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?
Begin bag-and-mask ventilation.
The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock?
Capillary filling time greater than 3 seconds Tachycardia
The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following?
Chlamydia
Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy?
Close the newborn's eyelids before applying eye patches. Inspect the eyes each shift for conjunctivitis. Reposition the baby every 2 hours.
A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate?
Direct tracheal suctioning by specially trained personnel.
The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment?
Hemoglobin Hematocrit Reticulocyte count Direct Coombs' test
A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment?
Increased urination
The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following?
Initial resuscitation
One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate?
Intravenous acyclovir (Zovirax) and contact precautions.
Mild or chronic anemia in an infant may be treated adequately which of the following?
Iron supplements or iron-fortified formulas
Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?
Jitteriness
The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following?
Newborns do not get overheated. Weight loss is not a complication of this system. Lights can stay on all the time. The eyes do not need to be covered.
The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation?
Physiologic jaundice occurs after 24 hours of age. Kernicterus causes irreversible neurological damage.
A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS?
Respiratory rate of 40 during sleep
Which findings would the nurse expect when assessing a newborn infected with syphilis?
Rhinitis Fissures on mouth corners Red rash around anus
The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?
Room-temperature IV running
A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do?
Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.
What indications would lead the nurse to suspect sepsis in a newborn?
Temperature of 97.0degreesF 2 hours after warming the infant from 97.4degreesF
The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy?
The newborn maintains a normal temperature
During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations?
The rise and fall of the chest
The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition?
Transient tachypnea of the newborn
The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care?
Urine specific gravity is assessed each voiding.
The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following?
"Visits must be scheduled between feedings."
The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best?
"Your baby is working hard to breathe and lying quite still, and has an IV."
The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse?
"Your body has made antibodies against the baby's blood that are destroying her red blood cells."