Maternal Newborn

A planning care for a requires phototherapy for hyperbilirubinemia

Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield. Lotion on the newborn's skin can cause burns during phototherapy. Therefore, the nurse should not apply lotion to the newborn's skin. The nurse should encourage frequent feedings throughout the treatment to prevent dehydration and to help promote excretion of bilirubin in the stools. The purpose of phototherapy is to reduce the level of bilirubin in the newborn. The nurse should ensure that the newborn has as much skin exposed to the lights as possible.

Hepes (simplex) virus, type 2

Erythromycin provides prophylaxis against ophthalmia neonatorum. It is given to prevent gonorrhea and chlamydia infections in the newborn. Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes. The client who has active herpes should receive a prescription for acyclovir. Metronidazole should be prescribed for bacterial vaginosis. The cesarean birth should be planned prior to the rupture of membranes. If rupture of membranes occurs, an emergency cesarean birth should be done as soon as possible, but every attempt should be made to prevent this situation.

planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?

The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.

Caring for a client who has a prescription for naloxone. Which of the following is the intended action of the med in relation to the CNS?

The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor. The use of naloxone in the newborn who has been exposed to narcotics during pregnancy could result in immediate withdrawal symptoms. By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.

planning care for a client who is at 35 weeks of gestation. Which of the following lab tests should the nurse obtain?

The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS. The nurse should obtain a rubella titer at the first prenatal visit to determine immunity to rubella. A client who is pregnant and does not have a titer to rubella must be taught to avoid exposure. The nurse should obtain a maternal blood type and Rh factor at the first prenatal visit to determine if the client will need to receive Rh(D) Immune Globulin at 28 weeks of gestation. The nurse should obtain a 1-hour glucose tolerance test at 24 to 28 weeks of gestation to screen for gestational diabetes.

Non-stress test

The purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the client orange juice to stimulate the fetus.

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate?

"Your child has a mild concussion; acetaminophen can be given." Following MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it would not be given. Also, this level of analgesia is not typically given for mild concussions. Ibuprofen is a common over-the-counter pain reliever; however, ibuprofen is a nonsteroidal anti-inflammatory medication, which reduces the ability of the blood to clot.

Weight gain during pregnancy

25-35 pounds A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

Caring for a client at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the patient is the priority?

the nurse should assess the client's heart rate. The primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified.

A primigravid client with diabetes at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which should the nurse include as the rationale for this test?

to startle and awaken the fetus Fetal acoustic stimulation involves the use of an instrument that emits sound levels of approximately 80 dB at a frequency of 80 Hz. The sharp sound startles and awakens the fetus and is used with nonstress testing as a method to evaluate fetal well-being. A fetoscope or Doppler stethoscope is used to listen to the fetal heart rate. Nipple stimulation or intravenous oxytocin is used to stimulate contractions. Ultrasound testing is used to determine amniotic fluid volume.

A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella?

"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?

"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breastfeeding infant has begun eating food.

Caring for a client who desires an intrauterine device for contraception. Which of the following findings is a contraindication for the use of this device?

An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy. An IUD is an appropriate method of contraception for women who have a history of thromboembolic disease because the IUD is not associated with clotting problems. The IUD is a good alternative to oral contraceptives, which are contraindicated for women who have a history of thromboembolic disease.

What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Apply gentle pressure to the site with a sterile gauze pad. If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. The primary care provider needs to be notified when bleeding cannot be stopped by conservative measures because this may signal a clotting disorder. Typically the neonate's circumcision site, including the diaper, is examined every 15 minutes for 1 hour to assess bleeding. Rechecking in 30 minutes may be too late if the neonate is actively bleeding.Securing the diaper tightly to apply pressure does not allow the nurse to observe whether bleeding has stopped.

Betamethasone (Celestone) Administer to client who is at 33 weeks of gestation to stimulate fetal lung maturity. Which consider adverse of this medication?

Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable. Betamethasone does not affect the newborn's ability to maintain body temperature. Betamethasone administered to the antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause, such as prematurity or respiratory insufficiency. Irritability is not an adverse effect of betamethasone.

discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make?

Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface. Epidural anesthesia will cause the maternal blood pressure to decrease rather than increase because of central nervous system depression. An epidural will be most effective when the client is in active labor, where there will be uterine contractions occurring at least every 3 to 5 min that last between 40 and 70 seconds, and contractions will be moderately strong in intensity. An adverse effect of epidural anesthesia is maternal hypotension, which can cause bradycardia in the fetus. This adverse effect has nothing to do with the timing of the epidural and is usually prevented by administering a bolus of 500 mL of an IV fluid prior to the insertion of the epidural catheter.

caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations is the newborn indicates toxicity due to the magnesium sulfate therapy?

Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position?

Posterior When a client has severe back pain during labor, the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the client's sacrum, causing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known prior to 8-cm dilation and a cesarean birth is performed. Fetal occiput anterior position does not increase the pain felt during labor.

Fetus position

ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex. The breech position indicates that the fetus is upright in the uterus and is presenting with the buttocks or feet. The transverse position indicates that the fetus is lying horizontally in the pelvis and is presenting with its shoulder. Mentum indicates that the fetus has fully extended its head and is presenting with its chin.

discussing diaphragm use with a client. Which of the following statements by client indicates an understanding of the teaching?

The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years. The diaphragm should remain in place at least 6 hr after intercourse. The diaphragm should be cleaned with mild soap and water and dried gently. Alcohol can dry out the diaphragm and can weaken the rubber. This will lead to an ineffective rate of birth control. The diaphragm should be rinsed with water and contraceptive jelly should be applied prior to placing the device into the vagina. Vaginal lubricants, mineral oil, and baby oil should not be used on the diaphragm, because they can weaken the rubber

A 3-year-old boy has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process?

The elevated fever, shallow respirations, decreased breath sounds, rales, harsh cough, and productive mucus are findings associated with pneumonia. Typically, there is no fever with asthma and cystic fibrosis, and bronchiolitis presents with a low-grade fever. Wheezing is associated with asthma and bronchiolitis; however, this was not found upon physical examination of this client. Bronchiolitis produces a dry cough, and pneumonia causes a productive, harsh cough. The client with cystic fibrosis typically presents with wheezing, rhonchi, and thick, tenacious mucus.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced. Which of the following responses should the nurse make?

The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication?

The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. When the client is at or near term with prolonged rupture of membranes, oxytocin induction is indicated. Intrauterine growth restriction is an indication for the use of oxytocin to induce labor. Induction of labor with oxytocin is suggested in postterm pregnancies.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest?

football hold After a cesarean birth, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in semi-Fowler's position, supporting the neonate's head in her hand and resting the neonate's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neonate easy access to the mother's breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate's mouth placement, is used by the mother to hold the breast and support it during breastfeeding. The cross-cradle hold is done when the mother holds the neonate's head in the hand opposite from the breast on which the neonate will feed and the mother's arm supports the neonate's body across her lap. This position can be uncomfortable because of the pressure placed on the client's incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line.

Which medication is considered safe during pregnancy?

insulin Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.

A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using which approach?

saline nose drops Saline nose drops are a natural remedy and can alleviate the discomfort .Clients who are pregnant should not take any medications without consulting the health care provider; therefore, oral antihistamines and oral decongestions should be avoided.Ice packs are not helpful in alleviating congestion. Warm moist towels might be helpful.

The nurse observes late decelerations on the fetal heart tracing of a woman in labor. Which interventions are most appropriate for the nurse to take to correct this situation? Select all that apply.

1. Oxygen administration 2. IV hydration 3. maternal position change A deceleration is identified as a deviation of the fetal heart rate from baseline that lasts for at least 10-15 seconds but for less than 2 minutes. Late decelerations are associated with compromised uteroplacental perfusion, and variable decelerations are associated with cord compressions. IV hydration increases blood volume and improves blood flow to the uterus. Position changes can also improve uterine blood flow. Administering oxygen is a measure to raise the mother's PO2levels, thus increasing the available amount of oxygen to be transferred to the fetus. Oxytocin increases contractions, which decreases blood flow to the fetus; therefore, this should not be given or should be decreased.

caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority?

A nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign present when the FHR increases 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress. Pre-eclampsia is a blood pressure reading of 140/90 mm Hg or greater, an increase of 30 mm Hg or more in systolic pressure or 15 mm Hg in diastolic over baseline on two occasions taken at least 6 hr apart. A blood pressure reading of 140/98 mm Hg is elevated and consistent with pre-eclampsia. However, this is not the priority finding. A fundal height of 33 cm is not within the expected reference range for a client who is at 36 weeks of gestation. The fundal height should be approximately the same as the number of weeks of gestation, plus or minus 2 cm.

providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition. A baseline human chorionic gonadotropin (hCG) level should be obtained following evacuation of the hydatidiform mole and then weekly until levels are normal for 3 consecutive weeks. Additional hCG levels should be obtained every 4 weeks for the next 6 to 12 months.

A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session?

I will call my physician if I notice redness, warmth, and pain in my breasts." Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after childbirth. The client should contact the physician if these symptoms occur. Episiotomy discomfort may persist for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks' postpartum. A temperature of 99.2° F (37.3° C) isn't significant. The client doesn't need to contact the physician if these signs or symptoms occur.

caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy?

Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action?

The knee-to-chest position helps lift the presenting part off the umblical cord. If, upon vaginal examination, a loop of cord is discovered, the nurse should keep gloved fingers in the vagina and push on the fetal presenting part to keep the part off the cord, thus relieving cord compression until the physician or midwife arrives. It is inappropriate to attempt an external cephalic rotation. Cord pulsations may not be felt; therefore, oxygen should be administered and electronic fetal monitoring should be put in place immediately to monitor the fetal heart rate and well being.

A 4-year-old child is admitted for a cardiac catheterization. Which is most important to include as the nurse teaches this child about the cardiac catheterization?

The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4,500 g) at birth, 1 hour after a vaginal birth?

The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Therefore, the nurse needs to assess for the possibility of complications. Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other common complications for an LGA neonate include hyperbilirubinemia from the bruising and polycythemia, cephalhematoma, caput succedaneum, molding, phrenic nerve paralysis, and a fractured clavicle. However, hyperbilirubinemia would not be evident 1 hour after birth. Hypercalcemia is not usually found in the LGA neonate. Hypocalcemia is common in infants of diabetic mothers. Hypermagnesemia may occur in neonates whose mothers received large doses of magnesium sulfate to treat severe preeclampsia.

A parent asks the nurse about using a car seat for a toddler who is in a hip spica cast. What should the nurse should tell the parent?

The toddler in a hip spica cast needs a specially designed car seat. The one that the parent already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar.

caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make?

This client needs reassurance that these feelings are normal and there is no reason for concern. These feelings are quite normal at the beginning of pregnancy.

caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is a contraindication for the care of the newborn?

This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors. The newborn who is exposed to narcotics often has an uncoordinated suck and swallow, predisposing the newborn to aspiration. Small, frequent feedings provide adequate caloric intake and reduce the risk of aspiration. Tight swaddling of the newborn discourages hyperactivity and provides comfort. Additionally, it reduces self-stimulation behaviors and protects the newborn's skin from abrasions. Maternal-newborn bonding is an important part of the newborn's care. The client's drug use, as well as the newborn's hyperactive behavior, often interferes with establishment of the maternal-newborn relationship.

caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan?

Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.

Caring for a client whose membranes have ruptured and is in active labor. the fetal monitor tracing reveals late decels

Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. The nurse should administer oxygen at 8 to 10 L/min by nonrebreather facemask to enhance placental perfusion The nurse should increase the client's IV fluids to increase circulating fluid volume

Assessing a client receiving magnesium sulfate as treatment for preeclampsia. which of the following clinical findings is the nurse's priority?

Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr. A fetal heart rate of 158/min is within the expected reference range. The acceptable range for fetal heart rate is 120 to 160/min. Expected reflexes for a client receiving magnesium sulfate is +2 or slight hyporeflexia. A respiratory rate of 16/min is within the expected reference range for a client receiving magnesium sulfate. The acceptable range for respiratory rate is 16 to 20/min.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

Wear a face mask when in close contact with the client RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.

The community health nurse is providing education to a client who gave birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage?

With a late postpartum hemorrhage (greater than 72 hours), women report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client?

complexity of care requirements Registered nurses are responsible for exhibiting critical thinking skills and caring for clients with fluctuating changes in their condition. This client requires extensive nursing care because the client has experienced a change in health status and requires enhanced surveillance. It is critical that the nurse caring for her recognizes if her condition further deteriorates. While it is appropriate to consider senior nursing staff, client wishes, and continuity of care, it is the responsibility of nurses to provide safe and ethical care. Therefore, in this context, client safety is the priority and requires that the charge nurse considers the complexity of her care requirements when assigning the appropriate care provider.

A mother is concerned about her 9-year-old child's compulsion for collecting things. The nurse's explanation is based on the understanding that this behavior is related to the cognitive ability to perform which functions?

concrete operations The school-aged child (age 7 to 11 years) who has achieved the cognitive abilities required to master concrete operations commonly collects various objects when learning to manipulate and classify these objects. Formal operations do not emerge until later (age 11 to 15 years).Coordination of secondary schemata is part of the sensorimotor phase of cognitive development (up to age 2 years).Tertiary circular reactions are part of the sensorimotor phase of cognitive development (up to age 2 years).

caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approx. 5 seconds.The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?

continue to routinely monitor the newborn This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priorityattention?

projectile vomiting The obstruction doesn't allow food to pass through the pyloris to the duodenum. When the stomach becomes full, the infant forcefully vomits for pressure relief. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach. Coffee ground emesis is a result of partially digested blood in the stomach, and not an expected finding with pyloric stenosis.