NCLEX-RN

Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location? slightly below the level of the umbilicus midway between the umbilicus and the symphysis pubis barely above the upper margin of the symphysis pubis slightly above the level of the umbilicus

Approximately 24 hours after childbirth, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day.Immediately after childbirth, the top of the fundus normally is midway between the umbilicus and the symphysis pubis.The fundus is barely palpable above the upper margin of the symphysis pubis 7 to 10 days after childbirth.Palpation of the uterus above the umbilicus may indicate urinary retention or retained placental fragments.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit? A pregnant nurse shouldn't care for a neonate whose mother was positive for human immunodeficiency virus (HIV). A nurse with young children shouldn't care for a neonate whose mother has gonorrhea. A nurse with young children shouldn't care for a neonate with erythema toxicum. A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

CMV exposure can affect the fetus; women who are pregnant should avoid contact with CMV-positive clients. HIV is transmitted via blood and body fluids; all staff should take contact precautions. When a mother has gonorrhea, a nurse should administer eye prophylaxis to the neonate to prevent neonatal ophthalmic infection. It isn't a concern for staff. Erythema toxicum is a common rash in infancy; communicability isn't a concern.

The nurse is developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis acute pain related to perineal sutures? Select all that apply. Apply an ice pack intermittently to the perineal area for 3 days. Avoid the application of topical pain gels. Administer sitz baths three to four times per day. Encourage the client to do Kegel exercises. Limit the number of times the perineal pad is changed.

Sitz baths help decrease inflammation and tension in the perineal area. Kegel exercises improve circulation to the area and help reduce edema. Ice packs should be applied to the perineum for only the first 24 hours; after that time, heat should be used. Topical pain gels should be applied to the suture area to reduce discomfort, as ordered. The perineal pad should be changed frequently to prevent irritation caused by the discharge.

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for which problem? normal uterine involution retained placental fragments puerperal infection uterine atony

The client is exhibiting signs and symptoms of puerperal infection, which include profuse foul-smelling lochia, chills, fever, and a uterus that is larger than expected for the first postpartum day. Infection may spread through the lymphatic system; antibiotic therapy is necessary.During normal uterine involution, the lochia becomes less profuse and should not be foul smelling.If the client had retained placental fragments, lochia rubra, not foul-smelling lochia serosa, would continue.Uterine atony refers to relaxation of the uterus and subsequent failure to contract properly. It may be a result of retained placental fragments.

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? "This type of stool indicates the infant may have diarrhea and should be seen in the office today." "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." "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.

What information would the nurse include in discharge instructions for post-circumcision care to the parents of a neonate? Select all that apply. The parents must note that the neonate has voided. Petroleum jelly or antibiotic ointment should be applied to the glans of the penis with each diaper change. The infant can have tub baths while the circumcision heals. Any amount of blood noted on the front of the diaper should be reported. The circumcision will require care for 2 to 4 days after discharge.

Circumcision is a common surgical procedure involving the removal of the foreskin of the penis. Parents must note the first void after circumcision, since this helps verify that the urethra is not obstructed. A lubricating or antibiotic ointment would be applied with each diaper change. Typically, the penis heals within 2 to 4 days, and circumcision care is needed for that period only. To prevent infection, the infant would not have tub baths until the circumcision is healed; sponge baths are appropriate. A small amount of bleeding is expected following a circumcision; parents would report only a large amount of bleeding.

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse? "Hold the bottle vertically so that the milk flows easily and the baby does not need to suck hard." "Keep the nipple full of milk throughout the feeding." "Burp the newborn only after the baby has finished the bottle." "Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks."

Paced bottle feeding allows the premature infant to have more control with feeding and mimics more natural feeding. The baby can pause and take a break when needed. The bottle is held nearly horizontal when it's in the infant's mouth. This way the milk won't pour into the newborn as it would with holding the bottle vertically or keeping the nipple full of milk. The baby should be burped at least once during the feeding to remove air bubbles.

The nurse is teaching a group of new parents about car seat safety. The nurse would know education has been effective when a parent makes which statement? "I can use a front-facing car seat when my baby reaches the size limit of the rear-facing seat." "I can use a front-facing car seat when my baby reaches one year of age and 20 pounds." "My baby can ride in the front seat facing forward if the airbag is safe for children." "I can buy a used car seat as long as it was manufactured within the past 15 years."

The current recommendation for car seat safety is for children to stay rear-facing until they exceed the size limit of their rear-facing seats. Often seats allow for rear-facing until the child weighs 40 pounds, and it is recommended to keep children rear-facing as long as possible. The car seat should be tethered, and the infant should be secure with the shoulder straps across the chest. Parents should be instructed to refer to the recommendations of the car seat manufacturer. Children should not be placed in the front seat with an airbag. It is not recommended that parents buy used car seats, but if they do, seats should be less than 10 years old.

The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. What nursing action should the nurse take next? Call for a cardiac consult. Note and tell the health care provider (HCP) when rounds are made. Place the neonate in reverse Trendelenburg position. Take the neonate's blood pressure in all four extremities.

The next nursing action in this situation would be to assess the blood pressure in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency, and the HCP needs to be notified as soon as the blood pressure data has been collected. Generally, prescribing a HCP consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities.

The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? Place the neonate on the client's fundus. Encourage the mother to breastfeed the infant. Massage the client's fundus continuously. Place the mother in a supine position.

The nurse should encourage the mother to breastfeed the infant. Neonatal sucking will induce the release of natural oxytocin, which will help contract the uterus and control uterine bleeding.Placing the neonate on the client's fundus will help keep the neonate warm but will not help to control excessive uterine bleeding.Gentle massage will help contract the fundus. Continuous massage can actually decrease uterine tone and lead to increased bleeding.Placing the mother in a supine position has no effect on uterine tone.

A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which statement indicates that the nurse should reinforce the instructions to the client? "I will wear a sports bra or a well-fitting bra for several days." "When showering, I will direct water onto my shoulders." "I will only use only water to clean my nipples." "I will use a breast pump to remove any milk that may appear."

The use of a breast pump to remove milk is contraindicated in bottle-feeding mothers. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fitting provides support and decreases stimulation. (Binders are not suggested.) Having the water in a shower land on the shoulders of the mother rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breast or bottle-feeding.

A client gives birth to a stillborn neonate at 36 weeks gestation. When caring for this client, which strategy by the nurse would be most helpful? Be selective in providing the information that the client seeks. Encourage the client to see, touch, and hold the dead neonate. Provide information about possible causes of the stillbirth only if the client requests it. Let the client's partner decide what information the client receives.

When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for the client to bond with the dead neonate and allow the neonate to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the client's partner decide which information the client receives is inappropriate.

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position? left side, with the neck slightly flexed back, with the head turned to the left side abdomen, with the head down back, with the neck slightly extended

When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffing" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly flexing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask.

A nurse notices that a newborn has a swelling in the scrotal area. The nurse interprets this swelling as indicative of hydrocele if what else occurs? The swollen bulge can be reduced. The increase in scrotal size is bilateral. The scrotal sac can be transilluminated. The bulge appears during crying.

A hydrocele, defined as fluid in the processus vaginalis, is determined when the scrotal sac can be transilluminated. A swelling in the scrotal area that can be reduced indicates an inguinal hernia. Both hydroceles and hernias can enlarge the scrotal sac, and both can be either unilateral or bilateral. A hernia typically is more obvious during crying.

The nurse is notified that a neonate who was discharged several days ago has a phenylketonuria (PKU) metabolic screening test result of 7 mg/dL. What action should the nurse take? Notify the parents to bring the neonate to the hospital to repeat the test. Notify the healthcare provider of the normal test result. Notify the blood bank because the neonate requires a blood transfusion. Notify the healthcare provider because the test result is critically elevated.

A normal test result for PKU metabolic screening is < 2 mg/dL; a level of 7 mg/dL is critically elevated. The nurse should immediately notify the healthcare provider who should then notify the parents and ask them to bring the neonate to the facility for immediate evaluation. The neonate should have a definitive serum test performed and should be evaluated by a pediatrician who specializes in inborn errors of metabolism such as PKU. Early intervention prevents intellectual disability that can occur as a result of PKU. The test does not need to be repeated prior to contacting the healthcare provider. Blood transfusions are not indicated for PKU.

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first? Obtain blood cultures. Start ampicillin 125 mg IV now. Give a 10 mL/kg bolus of fluid. Place a urinary bag for drug screening.

All of the orders that the health care provider initiated are important but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable.

The nurse recognizes that teaching about the need for an exchange transfusion in a neonate with erythroblastosis fetalis has been effective if the parents describe the purpose of the transfusion is what? to replenish the neonate's leukocytes to restore the fluid and electrolyte balance to correct the neonate's anemia to replace Rh-negative blood with Rh-positive blood

An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replenish the white blood cells or restore the fluid and electrolyte balance. The neonate's Rh-positive blood is replaced by Rh-negative blood.

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient? fat iron sodium calcium

Breast milk has a higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk.

Which common characteristics should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with Down Syndrome? Select all that apply webbed neck small testes congenital heart defects polydactyly epicanthal folds hypotonia

Down syndrome (trisomy 21) is an autosomal disorder. Characteristics include hypotonia, tongue protrusions, and epicanthal folds on the inner eye corner. Congenital heart defects occur in 40% to 60% of clients with Down syndrome. Other common characteristics include short stature, small head with flat profile, low set ears, Brushfield spots, excessive skin on the neck, broad hands with short fingers, and single palmar crease on the palm. Small testes and absence of sperm are associated with Klinefelter's syndrome (47 chromosomes). Polydactyly is associated with trisomy 13.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? removing the initial dressing for incision inspection monitoring pain status and providing necessary relief supporting self-esteem concerns about the birth assisting with parent-neonate bonding

Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next? Determine the length of the mother's labor. Notify the health care provider (HCP) immediately. Keep the neonate under the radiant warmer for 2 hours. Obtain a blood sample to check for hypoglycemia.

Ortolani maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the HCP promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani's maneuver to APNs or HCPs. Determining the length of the mother's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.

A family has taken home their newborn and later received a call from the child's health care provider (HCP) that the phenylketonuria (PKU) levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. What information should the nurse tell the parents about the disease? PKU is carried on recessive genes contributed by each parent. PKU is caused by a recessive gene contributed by either parent. PKU is cured by eliminating dietary protein for this child. PKU will not impact future childbearing for the family.

Phenylketonuria is a disease that is carried on the recessive genes of each parent. In order to be transmitted to a newborn, the infant inherits a recessive gene from each parent. Control of the disease is by reduction of the amino acid phenylalanine, which is present in all protein foods. The disease cannot be cured, but controlled. With each pregnancy, there is a 25% chance a child will inherit the disease.

The nurse reviews the contraception choices of a bottle-feeding postpartum client prior to discharge. The client wants to know why she needs to wait to resume the use of oral contraceptives. What is the nurse's best response? "The estrogen in combined hormonal contraceptives interferes with the involution process." "Clients cannot resume intercourse for 6 weeks after birth, so contraception is not needed." "Combined oral contraceptives potentiate the risk for blood clots immediately after birth." "The risk for bleeding is increased from the progestin in combined hormonal contraceptives."

Pregnancy and the immediate postpartum period is a hypercoagulable state that puts clients at risk for blood clots. Taking a combined hormonal contraceptive would expose the client to estrogen and further increase the risk of blood clots. Clients are advised to wait a minimum of 3 weeks after birth before taking estrogen-containing contraceptives. Oral contraceptives do not significantly affect the involution process in non-breastfeeding women. For oral contraceptives to be effective, they must be started before intercourse resumes. While some practitioners may advise clients to wait 6 weeks before resuming intercourse, other providers advise clients that they may resume after they no longer have lochia. Progestin does not significantly increase the risk for bleeding after birth, and there are no restrictions for beginning progestin-based contraceptives in non-breastfeeding women.

A nurse observes several interactions between a client and her neonate. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. She talks and coos to her neonate. She cuddles her neonate close to her. She does not make eye contact with her neonate. She requests that the nurse take the neonate to the nursery for feedings. She counts the fingers and toes of her neonate. She takes a nap when the neonate is also sleeping.

Talking to, cooing at, and cuddling with her neonate are positive signs that the client is adapting to her new role as a mother. Eye contact, inspecting the neonate by touching, and speaking help establish attachment with a neonate. Avoiding eye contact is a nonbonding behavior. Feeding a neonate is an important role of a new mother and facilitates attachment. Resting while the neonate is sleeping will conserve needed energy and allow the mother to be alert and awake when her infant is awake; however, it is not evidence of bonding.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? taking in taking on taking hold letting go

The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.

The nurse is assessing a client who had a cesarean birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus firm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued, and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. What should the nurse do first? Give the client pain medication. Have the client use the incentive spirometry. Ambulate the client from the bed to the hallway and back. Encourage the client to begin caring for her baby.

The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing flatus and begin peristaltic action in the gastrointestinal track. Medicating the client should be evaluated prior to ambulating, but it is probably too soon because the last dose was 3 hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incentive spirometry or asking the client to turn, cough, and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these interventions. Participating in infant care is another way to encourage the mother to move about, but the primary goal would be to have her walk on the unit, a more purposeful activity.

The nurse is caring for a neonate diagnosed with early onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents' teaching plan? Wear protective gear near the isolation incubator. Visit but do not touch the neonate. Wash hands thoroughly before touching the neonate. Wear a mask when holding the neonate.

The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. It is not necessary for parents to wear protective gear near the isolation incubator. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. The baby will not spread sepsis via respiratory droplets to parents, so it is not necessary for the parents to wear a mask.

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? "Gloves help protect you against infectious organisms." "Gloves guard you against my cold hands." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."

Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse's cold hands, the nurse wears them primarily to maintain standard precautions, which is required by the Occupational Safety and Health Administration.

After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? 6 months 12 months 18 months 24 months

A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.

Which assessment finding should a nurse interpret as abnormal for a 38-week gestation neonate who is 1 hour old? enlargement of the mammary glands slight yellowish hue to the skin blue hands and feet black and blue spots on the neonate's buttocks

A slight yellowish hue to the skin would be abnormal because it is too early for the neonate to be showing signs of jaundice. The finding should be reported immediately to the neonate's healthcare provider. All of the remaining responses are normal findings for a 1-hour-old neonate.

The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used. 1Clean povidone-iodine from client's vaginal area. 2Notify the health care provider (HCP) prescribing catheterization. 3Document the incident. 4File an incident report.

Correct response: Clean povidone-iodine from client's vaginal area. Notify the health care provider (HCP) prescribing catheterization. Document the incident. File an incident report.

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? increased use of glucose stores during a difficult labor and birth process interrupted supply of maternal glucose and continued high neonatal insulin production a normal response that occurs during transition from intrauterine to extrauterine life increased pancreatic enzyme production caused by decreased glucose stores

Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neonates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

The nurse is caring for a 12-hour-old neonate born to a mother with diabetes mellitus. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, oxygen saturation is 92% on room air, and the blood glucose 30 mg/dL (1.7 mmol/L). What is the priority intervention for the nurse to implement? Administer glucose. Administer oxygen. Assess the temperature. Start an IV.

Hypoglycemia is the most common metabolic disorder in infants. It is especially true for those infants born to type 1 diabetic mothers. In infants, blood glucose levels fall to a low point during the first few hours of life because the source of the maternal glucose is removed when the placenta is expelled. Hypoglycemia is defined as < 30 mg/dL (1.7 mmol/L) in the first 24 hours of life and < 45 mg/dL (2.6 mmol/L) thereafter, but this is qualified further by whether or not the infant is symptomatic. The symptoms of hypoglycemia include jitteriness, tachycardia, lethargy, cyanosis, a weak cry, and apnea. Early feeding helps prevent hypoglycemia. The treatment for hypoglycemia is a rapid-acting source of glucose. This can be given via a bottle or, if needed, an IV infusion. It is important to treat the infant early to prevent permanent neurological damage and seizures. The symptoms this infant is exhibiting are related to hypoglycemia, so correcting the blood glucose would be the priority.

When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? establishment of a deep respiratory pattern gain of 4 oz (120 g) by the time of discharge maintenance of normal body temperature maintenance of a normal bilirubin level

Hypothermia and temperature instability are primary problems in the postterm neonate, so maintaining a normal temperature pattern is the most appropriate goal. Postterm neonates have little subcutaneous fat, predisposing them to cold stress.Establishment of a deep respiratory pattern is inappropriate because all neonates tend to breathe in a shallow manner.A weight gain of 4 oz (120 g) may not be feasible because most neonates lose 5% to 15% of their birth weight during the first few days of life.All infants should be assessed for hyperbilirubinemia. Although polycythemia is common in postterm infants and may take a while to resolve, hyperbilirubinemia is not more common in the postterm neonate than it is in neonates born at term.

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague.

It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended, because the neonate needs increased fat in the diet. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

A viable neonate born to a 28-year-old multiparous client by cesarean birth because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which factor would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? mother's development of placenta previa neonate born preterm mother receiving analgesia 4 hours before birth neonate with sluggish respiratory efforts after birth

RDS is a developmental condition that primarily affects preterm infants before 35 weeks' gestation because of inadequate lung development from deficient surfactant production. The development of placenta previa has little correlation with the development of RDS. Although excessive analgesia can depress the neonate's respiratory condition if it is given shortly before birth, the scenario presents no information that this has occurred. The neonate's sluggish respiratory activity postpartum is not the likely cause of RDS but may be a sign that the neonate has the condition.

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure? placement of the neonate on a ventilator administration of bronchodilators through the nares suctioning of the neonate's nares with wall suction insertion of a chest tube into the neonate

The client data support the diagnosis of pneumothorax, which would be confirmed with a chest x-ray. Pneumothorax is an accumulation of air in the thoracic cavity between the parietal and visceral pleurae and requires immediate removal of the accumulated air. Resolution is initiated with insertion of a chest tube connected to continuous negative pressure. The neonate does not need to be placed on a ventilator unless there is evidence of severe respiratory distress. The goal of treatment is to reinflate the collapsed lung. Administering bronchodilators through the nares or suctioning the neonate's nares would do nothing to aid in lung reinflation.

Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases? Remove it with hand lotion. Clean the area with alcohol. Allow it to remain on the skin. Brush it off with a dry washcloth.

The white, cheese-like substance on the neonate's body creases is called vernix caseosa. Unless the vernix is stained with meconium or the mother has a bloodborne pathogen, it should be left on the skin because it serves as a protective coating that typically disappears within 24 hours of birth.Attempting to remove vernix caseosa (e.g., with lotion, alcohol, or a washcloth) will remove the protection and may damage the neonate's fragile skin.

A nurse completes the initial assessment of a full-term newborn and finds that the infant has increased vernix covering the newborn's body. Which of the following would be a priority action for the nurse? Assess for meconium aspiration. Assess the mother's due date in the medical record. Assess the infant for hypoglycemia. Assess for infant's vital signs.

Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. The nurse should assess for a discrepancy between EDC and gestational age by physical examination. Meconium aspiration is a sign of fetal distress but does not coincide with gestation and vernix covering. Hypoglycemia can occur at any gestation and is not associated with vernix covering of the skin. Vital signs would not be a helpful assessment because here is no indication that the infant is unstable with this finding.