Neonatal and High-Risk Neonatal Management

The nurse is measuring both the chest and head circumference during the full-term newborn's initial assessment. The newborn's father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate? 1.) "Comparing the measurements helps determine if there are head or chest size abnormalities." 2.) " Measuring the head circumference provides information about future intellectual ability." 3.) "Measuring the newborn's chest provides needed information when assessing cardiac health." 4.) " Comparing the head and chest measurements helps to determine future adult body size."

1.) "Comparing the measurements helps determine if there are head or chest size abnormalities." - The circumference of the normal newborn's head is approximately 2 cm greater than the circumference of the newborn's chest at birth. Any extreme difference in in head size may indicate microcephalous, hydrocephalus, or increased ICP.

A breastfeeding mother is being discharged with her 2-day-old,full-term newborn. the nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement? 1.) "He should have at least three wet diapers tomorrow." 2.) "He should have one stool per day during the next week." 3.) "At his 1-week checkup, he should weigh an additional 8 ounces." 4.) "He should nurse for 5 minutes on each breast to get enough milk."

1.) "He should have at least three wet diapers tomorrow." - This statement indicates the mother's understanding. A 3-day-old infant should produce at least three wet diapers. After 5 days of age, the newborn produce six well-saturated diapers per day.

The nurse is preparing the parents of a full-term, 24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? Select all that apply. 1.) Infant vital signs have been normal for the last 12 hours. 2.) The infant has passed at least three meconium stools. 3.) The infant has gained weight at the minimum 100 grams. 4.) The circumcision has had no bleeding for the last 2 hours. 5.) The infant has had six diaper changes in the last 24 hours. 6.) The infant has completed 2 successful consecutive feedings.

1.) Infant vital signs have been normal for the last 12 hours. 4.) The circumcision has had no bleeding for the last 2 hours. 6.) The infant has completed 2 successful consecutive feedings. - The American Academy of Pediatrics has determined that newborn discharge criteria include stable VS for 12 hours. - No bleeding from a circumcision for 2 hours is an expected discharge criterion. - Completing two successful consecutive feedings is included in the discharge criteria. Successful feeding includes verification that the infant is able to coordinate sucking, swallowing, and breathing while feeding.

The nurse meets the frantic father at the ED door. He says he just delivered his wife's full-term newborn in the car when the temperature outside is on 10 degrees F. In response to the cold environment, the nurse knows that the infants body will immediately begin to produce heat by which mechanism? 1.) Shivering 2.) Metabolizing body fat 3.) Dilating surface blood vessels 4.) Decreasing flexion of the extremities

2.) Metabolizing body fat -When skin receptors of full-term newborns perceive a drop in environmental temperature, the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat, thus producing heat that is transferred to the peripheral circulation.

The nurse assesses that the 8-hour-old infant's axillary temperature is 97 degrees F. Which intervention should the nurse implement first? 1.) document the findings as abnormal. 2.) Place the infants under a radiant warmer. 3.) Feed the infant formula that is warmed. 4.) Call the HCP to report the temperature.

2.) Place the infants under a radiant warmer. - The infant's axillary temperature of 97 degrees F is below the normal range of 97.7-98.9 degrees F. The infant should be gradually rewarmed under a temperature-controlled radiant warmer.

The client with oligohydramnios and possible intraline growth restriction gives birth. The newborn's 1-minute Apgar score was 6, and the 5-minute Apgar scare is 7. Which conclusion should the nurse make from this information? 1.) A low Apgar scare at 1-minute correlates with infant mortality. 2.) The 5-minute Apgar score of 7 is within normal parameters. 3.) Neurological problems are unlikely with a 5-minute score of 7. 4.) Oligohydramnios would not have affected the Apgar score.

2.) The 5-minute Apgar score of 7 is within normal parameters. - A 5-minute Apgar score at or above 7 is considered normal.

The first-time mother of the 2-hour-old full term newborn worriedly tells the nurse, "Sometimes black is coming out of my baby." After determining that the newborn has passed stool, which statement by the nurse is most appropriate? 1.) "Black stools could be from bleeding. I will notify your provider now." 2.) "Breastfeeding will cause all the baby's stool to be this dark in color." 3.) "Babies normally pass this type of stool initially; it is called meconium." 4.) "I'll check the baby's temperature; this occurs when babies need warming."

3.) "Babies normally pass this type of stool initially; it is called meconium." - The majority of full-term infants will normally pass the first meconium stool within 24 hours after birth. It is formed during fetal life from amniotic fluid and intestinal secretions and cells. It is greenish-black in color and normally contains occult blood.

The nurse reviews the labor and delivery record of the 2-hour-old male newborn and see this notation: "40 weeks' gestation, large for gestational (LGA) age." In response to this information, it is most important for the nurse to plan to assess the infants carefully for which condition? 1.) Acrocyanosis 2.) Undescended testicles 3.) Intact clavicles 4.) Hypothermia

3.) Intact clavicles - A major complication for LGA infants is birth trauma, such as a fractured clavicle, due to cephalopelvic disproportion from macrosomia.

The nurse find documentation in the 4-hour-old newborn's medical record that states, "Clamping of the umbilical cord was delayed until cord pulsatior ceased." When assessing and collecting additional information about the newborn, what effect should the nurse find as a result of the delayed cord clamping? 1.) More rapid expulsion of meconium by the newborn 2.) Increased level of newborn alertness after birth 3.) An increase in the newborn's initial temperature 4.) An increase in the newborn's hemoglobin and hematocrit

4.) An increase in the newborn's hemoglobin and hematocrit - Newborn Hgb and Hit values will be higher when placental transfusion, accomplished though delayed cord clamping, occurs at birth. Blood volume increases by up to 50% with delayed cord clamping.

A health postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother ask if she would be giving her baby supplemental iron. Which response by the nurse is correct? 1.) "Your breast milk provides all the iron your baby needs." 2.) "You, not you baby, will need an iron supplement daily." 3.) "Your pediatrician will prescribe iron drops for your baby." 4.) " You should feed your baby iron-fortified formula once daily."

1.) "Your breast milk provides all the iron your baby needs." - It is unnecessary to provide iron supplementation to a breastfeeding infant. Although iron content in breast milk is much lower than in iron-fortified formulas, the iron in breast milk is much more completely absorbed.

The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn's axillary body temperature between 97.7-98.9 degrees F? Select all that apply 1.) Carefully dry the infant immediately after birth. 2.) Place the infant skin-to-skin with the mother. 3.) Apply leggings to both of the newborn's legs. 4.) Cover the infant's head with a stocking cap. 5.) Place the infant in a bassinet close to the wall.

1.) Carefully dry the infant immediately after birth. 2.) Place the infant skin-to-skin with the mother. 4.) Cover the infant's head with a stocking cap. - Drying the newborn immediately after birth prevents heat loss through evaporation - Skin-to-skin contact between mother and baby at birth assists to maintain newborn body temperature. - The newborn's head is dried first after birth, and a stocking cap is placed on the head to conserve heat.

Calculating from the date of the mother's last menstrual period, the nurse determines that her newborn's gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? Select all that apply. 1.) Hypertonic flexion of all extremities. 2.) Sole creases on the anterior two-thirds of the sole. 3.) Well-defined incurring of the entire ear pinna. 4.) Presence of a prominent clitoris. 5.) Infant is able to support the head momentarily when pulled to a sitting position.

1.) Hypertonic flexion of all extremities. 3.) Well-defined incurring of the entire ear pinna. 5.) Infant is able to support the head momentarily when pulled to a sitting position. - As the fatal muscular tone matures, the posture becomes more flexed; thus the full-term newborn exhibits hypertonic flexion of all extremities. - Cartilage gives the ear its shape. At full term, the newborn ear has enough cartilage to produce a well-dined incurving of the entire pinna. - The full-term infant has the muscle strength to momentarily support his or her head when pulled to a sitting position.

As the nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis in the full-term newborn, the newborn's father ask if it is really necessary to put something into his baby's eyes. Which statement should be the basis for the nurse's response? 1.) It is the law in the United States that newborns receive this prophylactic treatment. 2.) This treatment is recommended but may be omitted at the parent's verbal request. 3.) The antibiotic used for the treatment can be given orally at the parent's request. 4.) The eye prophylaxis can be given anytime up until the infant is 1 year old.

1.) It is the law in the United States that newborns receive this prophylactic treatment. - Currently every U.S. State requires that newborns receive prophylactic eye treatment against gonorrheal conjunctivitis.

The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn's circumcision? Select all that apply. 1.) Monitor the newborn's penis hourly for 4 to 6 hours. 2.) Observe for and document the first voiding after circumcision. 3.) Use prepackaged commercial diaper wipes for perineal cleansing. 4. ) Apply petroleum ointment around the penis after each diaper change. 5.) Apply tightly a size-smaller diaper to provide hemostasis.

1.) Monitor the newborn's penis hourly for 4 to 6 hours. 2.) Observe for and document the first voiding after circumcision. 4. ) Apply petroleum ointment around the penis after each diaper change. - After circumcision, the newborn's penis should be closely monitored, especially for swelling and bleeding. - To evaluate for urinary obstruction, the infant should be monitored frequently for the first urination post-circumcision, and this finding should be documented. - Petroleum and gauze should be applied to the circumcision site with each diaper change to prevent bleeding and to protect healing tissue.

The postpartum client (G2P2) asks the nurse for suggestions to help facilitate her 3-year-old's attachment and acceptance of their newborn. Which action should the nurse suggest? 1.) Provide a doll for the 3-year-old to care for and nurture. 2.) Avoid bringing the 3-year-old to the "scary" hospital. 3.) Plan that dad cares for the 3-year-old and mom cares for the baby. 4.) Encourage the child to be "grown up" and accept the newborn.

1.) Provide a doll for the 3-year-old to care for and nurture. - Providing care to a doll encourages the 3-year-old to identify with the parents, which helps to decrease anger and regression to get attention.

The nurse evaluates that the newborn's Moro reflex is WNL. Which response by the newborn prompted the nurse's conclusion? 1.) Straightens extremities and then flexes them in response to a loud noise 2.) Right-side extremity extension when the head is quickly turned right 3.) Turns the head towards the right side when the right cheek is touched 4.) Attempts to walk when the sole of the foot touches a hard surface

1.) Straightens extremities and then flexes them in response to a loud noise - An intact Moro reflex is demonstrated when the newborn straightens the extremities and then flexes them in response to a loud noise.

The nurse completes teaching in preparation to discharge a mother and her 48-hour-old, full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn's father is overhead making which statement? 1.) "We need to face the infant car seat toward the back of the car." 2.) "I disarmed one front seat air bag so we can put the car seat in the front seat." 3.) "Let's check the car seat to make sure it will position the baby at a 45-degree angle." 4.) "I know the baby will need to be in the infant car seat until he is over 20 pounds."

2.) "I disarmed one front seat air bag so we can put the car seat in the front seat." - The parents should be advised to disarm air bags and that the rear vehicle seat is the safety place for children of any age to ride.

The nurse completed discharge education to the Native American parents of a 48-hour old, full-term infant. The nurse concludes that the mother needs additional teaching about jaundice when she makes which statement? 1.) "I know keeping my baby warm will help to decrease jaundice." 2.) "I know the jaundice should start to decrease after about 3 days." 3.) "The bilirubin causing the jaundice is eliminated in my baby's stools." 4.) "Feeding my baby frequently will help to decrease the jaundice."

2.) "I know the jaundice should start to decrease after about 3 days." - Peak bilirubin levels are reached at 3 to 5 days of age for Caucasian infants. However, Native American babies have higher bilirubin levels than Caucasian babies, and the jaundice persists for longer periods with no apparent ill effects.

The nurse has provided the mother with information about her newborn's milia. The nurse evaluates that the mother understands information when the mother makes which statement? 1.) "I will put lotion on my infant's nose in the morning and at night." 2.) "I understand these raised white spots will clear up without treatment." 3.) I realize the baby will need surgery to remove these skin lesions." 4.) "I will apply alcohol twice a day to the lesions until they disappear."

2.) "I understand these raised white spots will clear up without treatment." - This statement indicates the mother understands information about milia. No treatment necessary because it will clear spontaneously within the first month.

The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice? 1.) Remove the infant's diaper and look at the color of the genitalia. 2.) Apply pressure on the forehead for 3 seconds, release, and evaluate the skin color. 3.) Assess the color of the Pams and compare that skin color to the color of the soles. 4.) Open the infant's mouth to assess the color of the infant's tongue and palate.

2.) Apply pressure on the forehead for 3 seconds, release, and evaluate the skin color. - To differentiate cutaneous jaundice from normal skin color, the nurse should apply pressure with a finger over a bony area such as the forehead. If jaundice is present, the blanched area will look yellow before the capillaries refill.

The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply. 1.) Have the mother nap before interacting with her newborn. 2.) Dim the lights in the birthing room. 3.) Place the newly delivered infant on the mother's abdomen. 4.) Delay instilling the ophthalmic antibiotic for an hour. 5.) Play loud music to keep the infant stimulated. 6.) Ask the parents to delay phone calls for an hour after birth.

2.) Dim the lights in the birthing room. 3.) Place the newly delivered infant on the mother's abdomen. 4.) Delay instilling the ophthalmic antibiotic for an hour. 6.) Ask the parents to delay phone calls for an hour after birth. - Dimming the lights in the birthing room encourages the newborn to open his or her eyes. This in turn encourages eye contact between the parent and the newborn. - Skin-to-skin contact between mother and baby at birth improves mother-baby interaction. - Instillation of ophthalmic antibiotic ointment may cause temporary blurred vision in the newborn, thereby decreasing the ability to engage in eye-to-eye contact with the parents. This can be given up to 1 hour after birth. - The newborn is alert for up to 1 hour after birth. Parents should be encouraged to use this time for attachment and to delay phone calls.

During an assessment of the full-term, 1-hour-old newborn, the nurse obtains an apical HR of 120 bpm and auscultates a soft murmur at the left sternal border, third intercostal space. In response to these assessment findings, which action should be taken by the nurse? 1.) Immediately report the finings to the HCP. 2.) Document the heart rate and murmur. 3.) Recheck the murmur in the left side-lying position. 4.) Stimulate crying and then reassess the cardiac status.

2.) Document the heart rate and murmur. - Documentation of the findings is all that is require. both the HR and murmur are expected findings. The apical Hr of the term newborn is normally between 100 to 160 bpm. A murmur heard at the sternal border, third intercostal space, is most likely caused by delayed closure of the foramen oval, which functionally closes within 1 to 2 hours after birth. Permanent closure of the foramen oval occurs within 6 months to 1 year after birth.

The primiparous client, who delivered a term newborn, is a lesbian, achieved her pregnant via artificial insemination, and is in a monogamous relationship with a female partner. Which intervention should the nurse add to the newborn's care plan? 1.) Avoid acknowledging the client's lesbian relationship. 2.) Encourage the client's partner to participate in newborn cares. 3.) Ask the partner to leave the room when the newborn is present. 4.) Avoid telling the newborn's caregivers about the client's situation.

2.) Encourage the client's partner to participate in newborn cares. - The nurse should involve the partner in the newborn's care. This show the partner the same respect, caring, and attention shown to the partners of heterosexual mothers.

The agitated father of the 12-hour-old newborn reports to the nurse that his baby's hands and feet are blue. The nurse confirms acrocyanosis and intervenes by taking which action? 1.) Immediately stimulate the infant to cry. 2.) Explain that is is normal in a newborn. 3.) Assess the newborn's temperature. 4.) Assess the newborn's cardiac status.

2.) Explain that is is normal in a newborn. - Acrocyanosis, which is blueness of hands and feet, is normal newborn phenomenon in the first 24 to 48 hours after birth. the nurse should explain this to the father to relieve his anxiety.

While preparing parents of a 2-day-old, bottle-feeding newborn for discharge, the nurse recognized the parent's need for additional teaching about formula feeding. Which statement prompted the nurse's conclusion? 1.) "We plan to clean our baby's bottles in the dishwasher." 2.) "Placing the formula in a bowl of warm water will warm it." 3.) "We will put the bottle of unfinished formula in the refrigerator." 4.) "Using our city tap water to mix the powdered formula is safe."

3.) "We will put the bottle of unfinished formula in the refrigerator." - The formula remaining in the bottle after feeding has mixed with the infant's saliva and should be discarded, not refrigerated; formula is a good medium for bacterial growth.

The nurse is caring for a 30-year-old, single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client's lifestyle? 1.) Observe how the client interacts with her hospital visitors. 2.) Review the prenatal record for clues about the client's lifestyle. 3.) Ask the client what plans she has made for newborn care at home. 4.) Observe the relationship between the client and her newborn's father.

3.) Ask the client what plans she has made for newborn care at home. - Open-ended questions will encourage sharing of feelings and examination of available lifestyle options. Low income and lack of a reliable backup person are common problems for the single parent.

While supervising the LPN, the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse's conclusion? 1.) Assessed the newborn's heart rate apically 2.) Covered the newborn's head with a stocking cap 3.) Checked the newborn's temperature rectally 4.) Positioned the newborn supine while sleeping

3.) Checked the newborn's temperature rectally - The LPN needs additional instruction when observed monitoring the newborn's temperature rectally. Taking the temperature rectally may cause rectal mucosal irritation and increase the chances of rectal perforation.

The nurse discovers that an African couple from Kenya has not named their 48-hour-old, full-term newborn, and the infant and mother are being discharged to home. Which action should the nurse take in response to this information? 1.) Ask the parents to choose a name before discharge. 2.) Encourage other appropriate attachment behaviors. 3.) Document the discharge and that the baby is unnamed. 4.) Delay discharge until parental attachment is addressed.

3.) Document the discharge and that the baby is unnamed. - In Kenya, the naming of a child is an important event. In some areas, the name is given on the third day after birth and is marked by a celebration. Therefore, the only intervention needed is to document this information.

The mother of a healthy 15-hour-old newborn asks the nurse if the PKU blood test could be completed now on her infant because she and her infant are bring discharged to home. Which statement should be the basis for the nurse's response? 1.) The PKU test must be completed when the infant is at least 1 month of age. 2.) The parents must sign a consent form if the PKU test is completed before 24 hours of age. 3.) The PKU test is best if completed after the infant is 24 hours old but before 7 days of age. 4.) The PKU test is not needed if the infant is tolerating feedings without diarrhea or vomiting.

3.) The PKU test is best if completed after the infant is 24 hours old but before 7 days of age. - The PKU test should be performed after 24 hours of life and before the infant is 7 days old. This allows for sufficient intake of protein for accurate results.

The nurse assesses that the full-term newborn's head has molding. Considering this finding, which information should the nurse expect to see on the mother's labor and delivery documentation? 1.) Vaginal breech birth 2.) Planned cesarean birth, no labor 3.) Was in labor for 16 hours 4.) Precipitous delivery after a 30-minute labor

3.) Was in labor for 16 hours - A 16-hour labor will cause molding. Molding is a change in the shape of the fetal skull from the force of uterine contractions during labor pressing the vertex of the head against the cervix. The degree of molding caries with the amount and length of pressure exerted on the head. Thus a longer labor will increase molding.

The home-care nurse is education the partner of a 1-week-old newborn. Which instruction should the nurse included about the care of the newborn's umbilical cord? 1.) "Begin applying rubbing alcohol to the base of the cord stump three times a day." 2.) "Attempt to gently dislodge the cord if it had not fallen off in the next week." 3.) " When bathing, cover the cold with water twice a week until the cord falls off." 4.) "Continue to place the diaper below the cord when diapering the infant."

4.) "Continue to place the diaper below the cord when diapering the infant." - Folding the diaper below the cord avoids cord contact with urine and stool. A wet, soiled environment slows drying and increases the risk of infection.

The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn's HR is 80 bpm. What should the nurse do next? 1.) Assign a 2 for the Apgar score that pertains to the heart rate. 2.) Suction the excess secretions from the newborn's oral cavity. 3.) Wrap in warm blankets and place on the mother's abdomen. 4.) Begin immediate positive pressure ventilation on the newborn.

4.) Begin immediate positive pressure ventilation on the newborn. - A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff ventilation.

The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which actions should be taken by the nurse? 1.) Have the mother breastfeed her newborn now. 2.) Immediately feed the infant water with 10% dextrose. 3.) Report the results immediately to the health care provider. 4.) Document the information in the newborn's medical record.

4.) Document the information in the newborn's medical record. - Normal blood sugar values for a full-term newborn are 45 to 65 mg/dL. Therefore the only action require is to document the findings.

The nurse caring for a 32-weeks' gestation infant is about to perform a heel stick to obtain blood for a prescribed test. Which intervention should the nurse utilize to minimize the amount of pain the neonate will experience? 1.) Apply an ice pack 2.) Apply a heel warmer 3.) Give morphine sulfate 4.) Give sucrose or Sweet-Ease

4.) Give sucrose or Sweet-Ease - Sucrose activates the endogenous opioid system through taste. It is given 2 minutes prior to a painful procedure and has an analgesic effect lasting about 3-5 minutes.

The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn's anterior fontanel by which method? 1.) Lay the infant on his or her back. 2.) Stimulate the infant to cry strongly. 3.) Feel near the parietal and occipital bones. 4.) Place the infant in a sitting position.

4.) Place the infant in a sitting position. - To asses the anterior fontanel, the nurse should place the infant in a sitting position (45-900 degree) so its location, size, and any abnormalities can be identified. If indented-appearing, it could indicate dehydration; if bulging, it could indicated increased ICP.

The nurse and student nurse are caring for the postpartum client who delivered a term newborn 24 hours previously. The nurse recognizes that the student needs more information on newborn nutrition when making which statement? 1.) About half of the baby's calorie needs are met by the fat in breast milk or formula. 2.) Lactose is the primary source of carbohydrates in breast milk and formula. 3.) Calcium supplements are not needed for the newborn regardless of the feeding method. 4.) Supplemental water should be given to all infants daily, regardless of feeding method.

4.) Supplemental water should be given to all infants daily, regardless of feeding method. - Breast milk and formula contain almost 90% water, which meets the infant's water needs. Feeding supplemental water can cause hyponatremia and may result in seizures if water consumption is excessive.

Before beginning a newborn's physical assessment, the nurse reviews the newborn's medical record and sees this notation: "31 weeks' gestation." Considering this information, the nurse determines that a physical assessment of the infant should reveal which finding? 1.) Flexion of all four extremities 2.) The ability to suck 3.) The absence of lanugo 4.) Vernix covering the infant

4.) Vernix covering the infant - The preterm infant, 24 to 36 weeks' gestation, typically is covered with Vernix caseosa - a waxy, white substance secreted by the fetus's sebaceous glands in utero.