High Risk Neonatal Care

The nurse encourages parents of a stable neonate to start kangaroo care. The mother is hesitant. What should the nurse include when explaining the benefits of kangaroo care? Select all that apply 1. Decreases illness and infection 2. Prevents unstable temperature 3. Decreases excessive weight gain 4. Increases length of hospital stay 5. Decreases feeding intolerance

1,2,5

A 30-week gestation infant has been born at a small rural hospital with no neonatal intensive care unit (NICU). The health care team has decided that the infant will be transferred via ambulance to a regional care center 45 minutes away. Place the following nursing interventions in the correct order in which they will need to be performed. 1. Call and report pertinent information regarding maternal and neonatal histories to the regional care center. 2. Dispatch the appropriate healthcare team and equipment needed for the transport. 3. Inform the parents of the infant's status upon arrival at the regional care center. 4. Provide developmental care to the infant, including light and sound protection during transport.

1,2,4,3

Changes in cerebral blood flow can increase the risk of intraventricular hemorrhage (IVH). What nursing interventions help maintain steady cerebral blood flow? Select all that apply. 1. Keep the head of the bed flat. 2. Avoid lifting hips with diaper changes. 3. Provide developmental stimulation, such as lights and sounds. 4. Minimize crying. 5. Avoid having the infant become too hot or cold.

1,2,4,5

The nurse is planning to assess a neonate born at 25 weeks. Which would be an expected assessment finding? Select all that apply. 1. Hypotonic muscles 2. Creases on feet 3. Skin is pale 4. Lack of lanugo 5. Fused eyelids

1,5

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest

1,2,4,5

Bronchopulmonary dysplasia (BPD) is a chronic lung problem associated w/neonates who have been treated with mechanical ventilation. Which assessment is consistent with BPD? Select all that apply. 1. Chest x-ray shows lung hyperinflation 2. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 3. Intake matches output for at least 24 hours 4. Lung sounds clear throughout all fields 5. Increased pressure needed for ventilation

1,2,5

The nurse is caring for a neonate with a grade II Intraventricular Hemorrhage (IVH). Routine nursing care can cause fluctuations in cerebral blood flow. What nursing strategies will decrease the worsening of this condition? Select all that apply. 1. Minimize crying 2. Minimize stimulation 3. Keep head of at 45 degrees 4. Keep temperature normal 5. Position infant prone

1,2,4

The nurse is explaining necrotizing enterocolitis (NEC) to the student nurse. Which assessment findings are consistent with NEC? Select all that apply 1. Abdominal distention 2. Visible bowel loops 3. Normal vital signs 4. Abdominal discoloration 5. Decreased residuals prior to feeding

1,2,4

The nurse is seeing a neonate for an immediate cardiac assessment. What will the nurse be looking for? Select all that apply. 1. Heart sounds 2. Peripheral pulses 3. Blood glucose level 4. Capillary refill 5. Body temperature

1,2,4

A mother comes to visit her infant in the neonatal intensive care unit (NICU). She verbalizes anxiety regarding caring for the infant after discharge. What is the best response by the nurse? 1. "Being hands-on in your baby's care now will increase your confidence to handle things at home." 2. "Could you hire a home health nurse?" 3. "I understand your concern. You have a fragile newborn." 4. "We will write down all of your discharge instructions for you."

1

A neonate born at 28 weeks is 9 days old. During the nurse's assessment, symptoms of necrotizing enterocolitis (NEC) are noted. What is the highest priority symptom to address? 1. Unstable temperature 2. Bloody stools 3. Increased gastric residual 4. Abdominal distension

1

After birth, an infant received surfactant replacement therapy. The father questioned the nurse regarding the purpose of this therapy. What is the correct response by the nurse? 1. "It allows the infant to expand his lungs more easily." 2. "It prevents a lung infection." 3. "It causes bronchodilation so he can breathe better." 4. "It thins the mucus in the respiratory tract."

1

During labor, the nurse notes the presence of meconium stained fluid. What does the nurse prepare for at the time of delivery? 1. Suctioning of the infant's mouth and trachea 2. Administration of antibiotics to the mother 3. Vigorous tactile stimulation of the infant 4. Culturing of the placenta for pathology

1

Fetal alcohol syndrome (FAS) can cause physical anomalies. What assessment would the nurse identify as consistent with FAS? 1. Heart defects 2. Increased cranial size 3. Amniotic bands 4. Congenital hip dysplasia

1

The nurse is assessing a client during a prenatal visit. The client is at 30 weeks gestation. What assessment identifies a non-modifiable risk for preterm labor? 1. Placenta previa 2. Domestic violence 3. Periodontal disease 4. Incompetent cervix

1

The nurse is teaching parents to administer gavage feedings. Which statement made by the parents indicates to the nurse that further teaching is required? 1. "We should lay infant flat for feedings." 2. "We should use nonnutritive sucking during feeding." 3. "We should waken our infant for feeding tolerance." 4. "We should check the placement of the tube before each feeding."

1

Zika is an arbovirus that can infect the neonate in utero. What would the nurse explain as the method of transmission to the parents? 1. Trans-placental transfer 2. Ascending infection 3. Intrapartum exposure 4. Horizontal transmission

1

Despite maintaining a neutral thermal environment, a premature infant continues to have hypothermia. What intervention should the nurse perform next? 1. Check the infant's blood glucose. 2. Order an IV infusion of warmed saline. 3. Place the infant under double bili lights. 4. Continue to monitor and document findings.

1 Hypoglycemia can lead to other problems such as hypothermia and respiratory distress

A neonate with respiratory distress syndrome is being prepared for intubation and surfactant administration. The mother refuses any animal products. What should the nurse anticipate the healthcare provider (HCP) will order? 1. Colfosceril (Exosurf) 2. Poractant (Curosurf ) 3. Beractant (Survanta) 4. Calfactant (Infasurf)

1 Only synthetic surfactant

The nurse is administering oxygen to a 29-week gestation infant. To decrease the risk of retinopathy of prematurity (ROP), what safety measure does the nurse utilize? 1. Use an oxygen blender to administer oxygen. 2. Never let the infant's oxygen saturation drop below 95%. 3.Rotate the pulse oximetry site daily. 4. Administer humidified oxygen via a nasal cannula.

1 Oxygen blenders ensure exact concentration of oxygen making them more accurate

The nurse is teaching a father how to bottle feed his premature infant. What instructions should the nurse include in the teaching? 1. Pace the feeding to allow for breathing breaks. 2. Hold the baby in a supine position to prevent fatigue. 3. Use a high-flow nipple to make suckling easier. 4. A decrease in heart rate is expected and feeding can continue.

1 Preterm infants may not have a coordinated suck, swallow breath pattern. Pacing gives the infant time to breath

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1 Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify the primary health care provider (PHCP).

A nursing diagnosis for a very preterm neonate is ineffective thermos-regulation related to prematurity, lack of subcutaneous fat tissue, and environmental temperature. Which interventions would be the most important to perform immediately? Select all that apply. 1. Dry infant and discard wet linen 2. Place on pre-heated warmer 3. Keep head covered 4. Encourage kangaroo care 5. Place on mother's abdomen

1,2,3

The nurse is caring for a preterm infant who has recently started enteral feedings. What assessment findings would the nurse associate with the possible development of necrotizing enterocolitis (NEC)? Select all that apply. 1. Blood in the stool 2. Vomiting 3. Distended abdomen 4. Decreased gastric residuals 5. Visible bowel loops

1,2,3,5 Inflammation and damage to the bowel can result in occult blood in the stool, obstruction and slow gastric motility can lead to vomiting of stomach contents, obstruction and slow gastric motility can lead to abdominal distention, distended loops of bowel may become visible through the abdomen

A nurse is caring for a 28-week gestation infant. What assessment finding would the nurse determine as being consistent with this gestational age? 1. Abundant lanugo 2. Hypertonia 3. Flexed posture 4. Descended testes

1. Lanugo is present between 20-28 weeks, after which it begins to disappear on the face and trunk

The nurse is concerned that a newborn may be suffering from neonatal methamphetamine withdrawal. Which assessment finding is indicative of neonatal methamphetamine withdrawal? 1. Tachypnea and increased wakefulness 2. Poor weight gain and excoriated skin 3. Skin mottling and apnea 4. Hypotonia and high-pitched cry

2 Excoriated skin from loose stool and poor weight gain from feeding problems are symptoms of methamphetamine

A mother states to the nurse, "I want to breastfeed, but my baby is too fragile to hold." What can the nurse recommend to support breastfeeding by the mother? 1. Use donor breast milk to feed the infant. 2. Begin using a breast pump and storing milk for the infant. 3. Place cabbage on her breasts to prevent engorgement until the baby can nurse. 4. Use ice packs if breasts become firm and sore.

2

During the cardiac assessment of a preterm neonate, the nurse is likely to identify what abnormality? 1. Hypertension 2. Heart murmur 3. Capillary refill less than 3 seconds 4.Increased hemoglobin and hematocrit

2

The nurse is caring for an infant with a nasogastric tube. Before starting a feeding, what does the nurse do to check for proper placement? 1. Obtain an abdominal x-ray. 2. Inject air into the tube while listening to the abdomen. 3. Inject air into the tube while listening to the lungs. 4. Measure the tubing length remaining outside the nares.

2

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full- term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

2 Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress.

Abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines puts the neonate at risk for signs and symptoms of neonatal abstinence syndrome (NAS). The withdrawal of what substance can cause symptoms of NAS to start within 4 hours? 1. Cannabis 2. Alcohol 3. Narcotics 4. Barbiturates

2 Neonates exposed to alcohol in utero may demonstrate withdrawal symptoms within 3-12 hrs

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2 An infant born to a mother infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

2 Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin.

The nurse receives an order to begin trophic feeding at 2 ml/hour via nasogastric tube. The nurse recognizes what about trophic feedings? 1. Provides adequate nutrition 2. Enhances gastrointestinal functioning 3. Nasogastric feeding helps prevent choking 4. Allows continuous hydration

2 Small amounts of formula or breastmilk help to start digestion

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C (97.6° F).

2 The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2 The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority.

The nurse evaluates the gastric residual on an infant with a nasogastric tube and finds the volume to be high. In what position should the nurse place the infant to promote gastric emptying? 1. Supine 2. Prone 3. Head of bed elevated 30 degrees 4. Knees flexed to chest

2 prone or side lying promote gastric emptying

An infant has been diagnosed with bronchopulmonary dysplasia (BPD) following long term mechanical ventilation. What interventions should be included in the nursing care plan? Select all that apply. 1. Keep oxygen level at 100% at all times. 2. Gradually wean from mechanical ventilation per order. 3. Provide chest physiotherapy. 4. Restrict fluid intake. 5. Administer corticosteroids per order.

2,3,4,5

Which risk factor for hyperbilirubinemia is modifiable? Select all that apply. 1. Mother is Native American 2. Delayed cord clamping 3. Infrequent feedings in first 24 hours 4. Bacterial infection at birth 5. Breast feeding only in first 24 hours

2,3,4,5

The nurse is caring for a client with diabetes mellitus. She asks the nurse why strict blood glucose control is important. What is the correct response by the nurse? Select all that apply. 1. "High maternal blood glucose can cause hyperglycemia in the infant, as well." 2. "High maternal blood glucose can cause hypoglycemia in the infant." 3. "Congenital anomalies are more likely with uncontrolled diabetes." 4. "Precipitous births are more likely when blood glucose is uncontrolled." 5. "Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."

2,3,5

To prevent damage to the premature infant's skin, what interventions should the nurse perform? Select all that apply. 1. Bathe the infant with a mild, alkaline solution. 2. Use the minimum amount of tape needed to secure tubes or IV lines. 3. Avoid changing position and skin sheering. 4. Use water, air, or gel mattresses. 5. Assess skin at least once a shift for breakdown or infection.

2,4,5

The nurse is caring for an infant born at 42 weeks gestation. What assessment findings by the nurse are consistent with post-term infants? Select all that apply. 1. Abundant lanugo 2. Meconium staining 3. Vernix over back and face 4. Smooth skin with visible veins 5. Long fingernails

2,5

The neonatal nurse practitioner rounded on the unit and left new orders. After reviewing the following orders, the nurse prioritizes the infant's care. Place the interventions in the correct order in which they need to be completed. 1. Heel stick blood glucose before each feeding. 2. Feed 15 mL donor breastmilk every 3 hours. 3. Start single light phototherapy. 4. Administer 0.5 mL Hepatitis B vaccine IM.

3,1,2,4

A mother asks the nurse when her infant's nasogastric tube may be removed. What is the correct response by the nurse? 1. "Once he is eating at least 60 mL per feeding." 2. "When he reaches an adjusted gestational age of 34 weeks." 3. "When he demonstrates a coordinated suck, swallow, breathe pattern." 4. "Once he can maintain a blood glucose level above 50 mg/dL."

3

A nasogastric tube has been ordered for an infant who is not tolerating oral feedings. How does the nurse measure the correct length to insert the tube? 1. Take the infant's length in centimeters and divide by 3 2. Measure from mouth, to ear, to lower sternum 3. Measure from nose, to ear, to lower sternum 4. Measure the distance from mouth to umbilicus

3

The nurse is admitting a 28-week neonate to the NICU. Which assessment would indicate an intraventricular hemorrhage (IVH)? 1. Tachycardia 2. Hypoglycemia 3. Hypotonia 4. Hypertension

3

The nurse knows that maternal alcohol, tobacco, cannabis, and cocaine abuse can all cause many long-term adverse effects. Which assessment findings can be attributed to all of these substances? 1. Lower IQ and language problems 2. Congenital infections and congenital anomalies 3. Low birth weight and attention deficit disorder 4. Mental retardation and aggressiveness

3

The student nurse asks about the use of surfactant. Which statement indicates to the nurse that the student understands the teaching? 1. "Surfactant increases surface tension of alveoli." 2. "Adverse effects include hypertension and hypotonia." 3. "Surfactant decreases risk of bronchopulmonary dysplasia." 4."Surfactant reduces lung compliance and work of breathing."

3

To prevent heat loss from evaporation immediately after delivery, what is the most important nursing intervention? 1. Place the neonate on a chemical mattress. 2. Keep the neonate's head covered with a hat. 3. Dry the neonate gently and replace the wet linen. 4. Place the neonate in a double-walled incubator.

3

What assessment does the nurse know indicates a high risk of retinopathy of prematurity (ROP)? 1. Advanced maternal age 2. Oxygenation of 87 to 94% 3. Intraventricular hemorrhage 4. Use of oxygen blenders

3

Which bilirubin level in a healthy term or near-term neonate would the nurse determine is concerning, but not critical, at 36 hours after birth? 1. 1 to 3 mg/dL 2. 4 to 5 mg/dL 3. 10 to 14 mg/dL 4. 15 to 20 mg/dL

3

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery."

3

The nurse is assessing a preterm neonate immediately after delivery. Which assessment finding indicates respiratory distress? Select all that apply 1. Cyanosis of hands and feet 2. Low body temperature 3. Grunting on exhalation 4. Intercostal retractions 5. Slow capillary refill

3,4

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

3,4,5 A newborn of a woman who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3 Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation.

The nurse is caring for an infant born to a woman with diabetes. The nurse notes that the infant moves the left arm, but the right arm remains flaccid. What order does the nurse anticipate? 1. Head CT 2. Electroencephalogram 3. Chest X-ray 4. Electromyography

3 Infants born to mothers with diabetes are more likely to suffer birth injuries such as a broken clavicle which can be seen on a chest X-ray

The nurse is preparing a woman to have a lecithin/sphingomyelin (L/S) ratio performed. What education should the nurse provide to the client about the procedure? 1. "This blood sample will be taken from the baby's umbilical cord." 2. "Do not eat or drink anything 12 hours prior to the procedure." 3. "After the test, report any leaking of amniotic fluid to your provider." 4. "The results will let us know if there are any chromosomal abnormalities with your baby."

3 The L/S ratio obtains a sample of amniotic fluid, which could potentially cause rupture of membranes. The woman should report leaking of fluid

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the primary health care provider (PHCP).

3 The penis is normally red during the healing process after circumcision.

The parents of an infant diagnosed with patent ductus arteriosus (PDA) met with the cardiologist. What statement by the mother indicates to the nurse that she understands the teaching? 1. "My baby will need a heart transplant." 2. "There was an abnormal shunt that formed during pregnancy." 3. "The open shunt can be closed with a clip or suture." 4. "He will need extra fluids because his blood pressure will be lower."

3 PDA can be surgically remedied with a clip, suture, or coil

The nurse is teaching the parents of a preterm infant about necrotizing enterocolitis (NEC). What statement indicates to the nurse that teaching has been successful? 1. "This condition causes increased digestion and diarrhea." 2. "Full term infants are at the highest risk for developing NEC." 3. "The rotavirus vaccine will help protect my baby from NEC." 4. "Breastfeeding will help protect my baby's gut from NEC."

4

The registered nurse (RN) is educating a mother whose infant is receiving phototherapy for hyperbilirubinemia. What statement by the mother does the RN identify as correct? 1. "I cannot hold my infant for feedings." 2. "My infant should wear a light shirt while under the lights." 3. "I should leave my infant in the same position under the lights." 4. "I will feed my baby frequently while on phototherapy."

4

A nurse is assessing a 28-week neonate who is on 25% oxygen at 0.5 L/m via nasal cannula. The infant is pale with O2 saturation of 75%. What is the first intervention to perform? 1. Call the health care provider for orders. 2. Increase the oxygen percentage. 3. Increase the oxygen flow rate. 4. Assess the infant's airway.

4

A premature neonate with severe hyperbilirubinemia is starting phototherapy. What nursing intervention is the most important? 1. Bank of lights covered with plexiglass 2. Only diaper in place for maximum exposure 3. Feed neonate every 2 to 3 hours 4. Eye patches in place while under lights

4

Alcohol related birth defects (ARBD) affect the heart, skeleton, kidneys, and ears. The nurse is the most concerned about what assessment? 1. Facial anomalies 2 Cognitive problems 3. Brain abnormalities 4. Cardiac anomalies

4

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

4

The nurse is caring for an infant with respiratory distress syndrome (RDS) who is intubated. What assessment does the nurse perform to ensure proper placement of the endotracheal tube (ET)? 1. Check arterial blood gas values (ABG). 2. Visually inspect the oropharynx. 3. Obtain a chest x-ray. 4. Auscultate bilateral breath sounds.

4

The nurse is teaching parents about home use of the fiberoptic bili blanket. Which statement by the mother indicates effective teaching? 1. "I should dress my baby before wrapping him in the bili blanket." 2. "I should wrap my baby from neck to toe in the bili blanket." 3. "I can unwrap my baby for feedings." 4. "I should keep the bili blanket on 24 hours a day."

4

The nurse is teaching parents of a preterm neonate about feedings in the newborn intensive care unit (NICU). What statement about nutrition indicates an understanding of the teaching? 1. "My baby can breastfeed right away." 2. "My baby can only have special formula." 3. "My baby will need breast milk only." 4. "My baby will need fortified breastmilk."

4

A client calls the nurse to her room and states, "The baby is really sleepy and hasn't been feeding well." The nurse notes the infant is jittery. What additional assessment should the nurse perform? 1. LATCH score 2. Urine output 3. Weight 4. Blood glucose

4 Jitteriness is an indication of hypoglycemia

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity." 2. "The medicine will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding"

4 Phytonadione is necessary for the body to synthesize coagulation factors. It is administered to the newborn to prevent bleeding disorders.

Place the steps for neonatal gavage feedings in the correct order. 1. Check for residuals before starting feeding. 2. Assess the neonate for feeding intolerance. 3. Check for placement prior to feeding. 4. Measure the tube accurately.

4,3,1,2

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4,5,6