NCLEX Maternity: Newborn
What to do if feeding newborn does not raise BG about 45?
If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should notify the health care provider and prepare to administer IV glucose.
Why are infants of diabetic mothers at risk for hypoglycemia after birth?
Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels.
Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation?
1) Abundant lanugo on shoulders and back 2) Smooth, pink skin and visible veins 3) Flat areolae without palpable buds
What should the nurse do immediately after an infant is born?
1) Always wear gloves when handling the newborn before first bath 2) Cover newborn to maintain temp of 97.5 - 99 3) Give vitamin K IM 4) Suction pharynx first, then nares
The nurse is teaching about prevention of sudden infant death syndrome (SIDS) to a group of parents with newborns. Which recommendations does the nurse suggest for SIDS prevention? S
1) Breastfeeding 2) Smoking cessation 3) Up to date vaccine
An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired?
1) Burping the infant often 2) Feeding in an upright position 3) Using a specialty bottle or nipple 4) Feed over 20-30 mins
A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene?
You will need to formula feed your newborn to reduce the risk of transmitting the virus via breastmilk
What is the average head circumference of a newborn?
13-14 inches
What are normal BG levels in a newborn?
between 70-100 but above 40
What is the holosystolic murmur that is loudest over the left mid-sternal border?
holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life.
What is a normal respiratory rate for newborns?
30-60/min with periodic pauses lasting <20 seconds.
What is trisomy 18 Edwards syndrome?
A life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday.
What are signs of hypoglycemia in a newborn?
Common signs include poor feeding, jitteriness, and irritability.
What should the nurse do if ineffective breastfeeding occurs?
Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) (Option 1) Teach how to express milk by hand and use an electric pump to enhance milk production (Options 2 and 4) Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings?
BG of 60 Respirations of 56/min White papules on bridge of nose
Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take?
Begin positive pressure ventilation - Neonatal resuscitation interventions after birth are initiated at 30-second intervals, with continual assessment of the newborn's adaptation to extrauterine life. Positive pressure ventilation (PPV) is started if heart rate is <100/min; compressions are started if the newborn's heart rate remains <60/min after at least 30 seconds of quality PPV.
What does a single transverse crease in the palm indicate in newborns?
Downs syndrome - Other signs include small and low-set ears, flat nose bridge, protruding tongue, and hypotonia.
How do newborn glucose levels work after birth?
During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. - As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately.
The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect?
Elevated Hematocrit level - Poorly controlled diabetes negatively affects fetal oxygenation throughout pregnancy. In utero, erythropoiesis accelerates to meet additional fetal oxygen needs. Due to overproduction of red blood cells, infants of diabetic mothers commonly experience polycythemia (ie, hematocrit >65%).
The nurse is caring for a 6-hour-old, full-term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. What is the nurse's first action?
Feed the newborn
After giving birth to a full-term neonate, the client informs the nurse that she has been taking hydrocodone on a regular basis for several years. What should the nurse plan as part of the neonate's care?
Feed the newborn while swaddled
The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider?
Hemoglobin level of 24.9 - Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because increased circulatory viscosity increases the risk for thrombus formation and stroke.
A client denies illicit drug use but has some suspicious behaviors. The client's neonate has a low birth weight. What other signs would lead the nurse to suspect neonatal abstinence syndrome?
Irritability and restlessness Poor feeding and loose stools Stuffy nose and frequent sneezing Neonatal abstinence syndrome affects the autonomic nervous system (stuffy nose, frequent yawning), gastrointestinal tract (poor feeding, diarrhea), and central nervous system (irritability, restlessness, high-pitched cry).
What interventions should the nurse implement when caring for an infant with necrotizing enterocolitis?
Measure abdominal girth daily Place patient supine and undiapered NPO and get suction thru NG tube to decompress GI tract Parenteral hydration and nutrition and IV antibiotics are given.
The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings?
Plantar creases up the entire sole Toes fan outward White pearl like cysts
When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding?
Shivering
When does the newborn of a mother with Hep B get the vaccine and immunoglobulin?
The hepatitis B immune globulin and vaccine should be administered to the newborn within 12 hours of birth.
What are the symptoms of cold stress in an infant?
The nurse should carefully assess for signs of cold stress, which include decreased temperature, altered mental status, bradycardia, hypoxia, hypotonia, and a weak cry and/or suck.
How many arteries and veins in the umbilical cord?
Two arteries and one vein
A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency?
Vomit that is green - Green vomit represents bile from the intestine, which could indicate a bowel obstruction.
Is a heart murmur expected in newborns?
Yes, a physiologic heart murmur is expected in the first 48 hours of life during transition from fetal to neonatal circulation. - Newborns with congenital heart disease have a pathologic heart murmur associated with other assessment findings (eg, abnormal vital signs, cyanosis, poor feeding).
