Newborn

The highest priority intervention the nurse must perform before resuscitating a newborn with asphyxia is:

Suctioning

A newborn infant is diagnosed with imperforate anus. The nurse plans care, knowing that which of the following appropriately describes a characteristic of this disorder?

Incomplete development of the anus Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Priority Nursing Tip: Monitor the newborn infant with imperforate anus for the presence of stool in the urine and vagina; this could indicate a fistula.

The nurse correctly describes physiologic jaundice to the parents of a newborn in the following manner:

It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life.

Symptoms of polycythemia:

tachycardia and congestive heart failure due to the increase in blood volume; respiratory distress with grunting, tachypnea, and cyanosis, increased oxygen need, or respiratory hemorrhage due to pulmonary venous congestion, edema, and hypoxemia; hyperbilirubinemia due to increased numbers of red blood cells breaking down and a decrease in peripheral pulses, discoloration of extremities, alteration in activity or neurologic depression; renal vein thrombosis with decreased urine output, hematuria, or proteinuria due to thromboembolism.

A mother and her 3-week-old infant arrive at the well-baby clinic for a rescreening test for phenylketonuria (PKU). The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/ dL. The nurse interprets this level as: 1 Normal 2 Inconclusive 3 Requiring a repeat study 4 Elevated and indicating PKU

Answer: 1 Rationale: The normal PKU level is less than 2 mg/ dL. With early postpartum discharge , screening is often performed when the infant is less than 2 days old because of the concern that the infant will be lost to follow up. Infants should be rescreened by the time that they are 14 days old if the initial screening was done when the infant was 24 to 48 hours old. Priority Nursing Tip: All 50 states require routine screening of all newborns for phenylketonuria.

A nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe? 1 Peeling of the skin 2 Smooth soles without creases 3 Lanugo covering the entire body 4 Vernix that covers the body in a thick layer

Answer: 1 Rationale: The postterm infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leatherlike skin over the body, which is called desquamation. The preterm infant (born between 24 and 37 weeks of gestation) exhibits smooth soles without creases, lanugo covering the entire body, and thick vernix covering the body. Priority Nursing Tip: The postterm infant may exhibit meconium staining on the fingernails, long fingernails and hair, and the absence of vernix.

A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse responds, knowing that which of the following could have a psychosocial impact if this condition is not corrected? 1 Atrophy 2 Infertility 3 Malignancy 4 Feminization

Answer: 2 Rationale: Infertility can occur males with this condition because proper function of the testes in producing fertile sperm depends on a temperature of less than 98.6 ° F. The psychological effects of an "empty scrotum" could affect the client's perception of self and the ability to reproduce.

A nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice? 1 Presence of a cephalhematoma 2 Infant blood type of O negative 3 Birth weight of 8 pounds 6 ounces 4 A negative direct Coombs' test result

Answer: 1 Rationale: A cephalhematoma is swelling caused by bleeding into an area between the bone and its periosteum (does not cross over the suture line). Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves (usually within 6 weeks) and is absorbed into the circulatory system.

A nurse in the newborn nursery receives a telephone call and is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, the nurse should take which important action? 1 Obtain the newborn infant's blood type and direct Coombs' results from the laboratory. 2 Obtain the necessary equipment from the blood bank needed for an exchange transfusion. 3 Call the maintenance department and ask for a phototherapy unit to be brought to the nursery. 4 Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization. Silvestri, Linda Anne (2011-11-23). Saunders Q&A Review for the NCLEX-RN® Examination (Saunders Q&A Review for NCLEX-RN) (Kindle Locations 26319-26325). Elsevier Health Sciences. Kindle Edition.

Answer: 1 Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory.

A nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse obtains equipment to perform which diagnostic test? 1 Serum insulin level 2 Heelstick blood glucose 3 Rh and ABO blood typing 4 Indirect and direct bilirubin levels

Answer: 2 Rationale: After birth the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage caused by inadequate circulation of glucose to the brain.

A nurse is teaching a mother with diabetes mellitus who delivered a large-for-gestational-age (LGA) male infant about the care of the infant. The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for additional information about the care of the infant? 1 "I will talk to my baby when he is in a quiet, alert state." 2 "I will allow my baby to sleep through the night, because he needs his rest." 3 "I will breast-feed my baby every 2 ½ to 3 hours and will use arousal techniques." 4 "I will watch my baby closely, because I know that he may not be as mature in his motor development."

Answer: 2 Rationale: LGA infants tend to be more difficult to arouse and therefore must be aroused to facilitate nutritional intake and attachment opportunities. These infants also have problems maintaining a quiet, alert state. It is beneficial for the mother to interact with the infant during this time to enhance and lengthen the quiet, alert state.

A nurse is preparing to assess the respirations of a newborn infant just admitted to the newborn nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which of the following is noted? 1 A respiratory rate of 20 breaths per minute 2 A respiratory rate of 40 breaths per minute 3 A respiratory rate of 90 breaths per minute 4 A respiratory rate of 100 breaths per minute

Answer: 2 Rationale: Normal respiratory rate varies from 30 to 60 breaths per minute when the infant is not crying. Respirations should be counted for one full minute to ensure an accurate measurement because the newborn infant may be a periodic breather . Observing and palpating respirations while the infant is quiet promotes accurate assessment. Palpation aids observation in determining the respiratory rate. Priority Nursing Tip: The newborn infant's respiratory rate and apical heart rate are counted for one full minute to detect irregularities in rate or rhythm. Test-Taking

A nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory status is improving? 1 Edema of the hands and feet 2 Urine output of 3 mL/ kg/ hour 3 Presence of a systolic murmur 4 Respiratory rate between 60 and 70 breaths per minute

Answer: 2 Rationale: RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid, which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Therefore normal urination is an early sign that the neonate's respiratory condition is improving (normal urinary output is 2 to 5 mL/ kg/ hour). Edema of the hands and feet occurs within the first 24 hours after the development of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress. Priority Nursing Tip: Surfactant replacement therapy is used to treat respiratory distress syndrome. The surfactant is instilled into the endotracheal tube.

A nurse admits a newborn infant to the nursery. On assessment of the infant, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates: 1 Dehydration 2 A normal finding 3 Increased intracranial pressure 4 Decreased intracranial pressure

Answer: 2 Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated. Priority Nursing Tip: The anterior fontanel is a diamond-shaped area where the frontal and parietal bones meet. It closes between 12 and 18 months of age. Vigorous crying may cause the fontanel to bulge, which is a normal finding.

A nurse in the newborn nursery receives a telephone call from the delivery room and is told that a post-term small for gestational age (SGA) newborn will be admitted to the nursery. The nurse develops a plan of care for the newborn and documents that the priority nursing action is to monitor: 1 Urinary output 2 Blood glucose levels 3 Total bilirubin levels 4 Hemoglobin and hematocrit

Answer: 2 Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately.

A nurse is preparing to assess the apical heart rate of a newborn infant. The nurse performs the procedure and notes that the heart rate is normal if which of the following is noted? 1 A heart rate of 90 beats per minute 2 A heart rate of 140 beats per minute 3 A heart rate of 180 beats per minute 4 A heart rate of 190 beats per minute

Answer: 2 Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Priority Nursing Tip: To measure the apical heart rate of a newborn infant the nurse should place the stethoscope at the fourth intercostal space and auscultate for 1 full minute.

A nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding would indicate a normal respiratory rate? 1 28 breaths per minute 2 50 breaths per minute 3 70 breaths per minute 4 80 breaths per minute

Answer: 2 Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute.

A nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that the stomach capacity for a newborn infant is approximately: 1 5 to 10 mL 2 10 to 20 mL 3 30 to 90 mL 4 75 to 100 mL

Answer: 2 Rationale: The stomach capacity of a newborn infant is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant, and 75 to 100 mL for a 2- to 3-week-old infant. Priority Nursing Tip: Instruct the mother not to heat a bottle of formula in a microwave oven.

A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of: 1 Hypoglycemia 2 Respiratory distress syndrome 3 Meconium aspiration syndrome 4 Transient tachypnea of the newborn

Answer: 3 Rationale: Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome (MAS). MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth. The symptoms noted in the question are unrelated to hypoglycemia. Respiratory distress syndrome is a complication of preterm infants. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section. Priority Nursing Tip: The health care provider is notified if meconium is noted in the amniotic fluid during labor. Although meconium is sterile, aspiration can lead to lung damage, which promotes the growth of bacteria; thus the newborn needs to closely monitored for infection.

A nurse determines that a client understands the purpose of a vitamin K (phytonadione) injection for her newborn if the client states that vitamin K is administered because newborns: 1 Lack vitamins 2 Have low blood levels 3 Lack intestinal bacteria 4 Cannot produce vitamin K in the liver

Answer: 3 Rationale: The absence of normal flora needed to synthesize vitamin K in the normal newborn gut results in low levels of vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. From a low point at about 2 to 3 days after birth, these coagulation factors rise slowly, but do not approach normal adult levels until 9 months of age or later. Priority Nursing Tip: In the newborn, vitamin K (phytonadione) is administered in the lateral aspect of the middle third of the vastus lateralis muscle of the thigh.

A nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse tells the new mothers: 1 If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it. 2 All that is necessary is to wash the cord with antibacterial soap and allow it to air dry once a day. 3 Apply alcohol to the cord, ensuring that all areas around the cord are cleaned two to three times a day. 4 Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause the newborn infant pain.

Answer: 3 Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are : (1) lift the cord, (2) wipe around the cord starting at the top, (3) clean the base of the cord, and (4) fold the diaper below the umbilical cord to allow the cord to air dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.

A nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant? 1 Placing the infant under phototherapy 2 Keeping the infant NPO until the second period of reactivity 3 Encouraging the mother to breast-feed the infant every 2 to 3 hours 4 Encouraging the mother to offer a formula supplement after each breast-feeding session

Answer: 3 Rationale: To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium. Offering the infant a formula supplement will cause nipple confusion and decrease the amount of milk produced by the mother. Breast-feeding should begin as soon as possible after birth while the infant is in the first period of reactivity. Delaying breast-feeding decreases the production of prolactin, which decreases the mother's milk production. Phototherapy requires a physician's prescription and is not implemented until bilirubin levels are 12 mg/ dL or higher in the healthy term infant. Priority Nursing Tip: The appearance of jaundice in the first 24 hours of life is abnormal and must be reported to the physician.

A nurse is performing an admission assessment on a newborn infant admitted to the nursery with the diagnosis of subdural hematoma after a difficult vaginal delivery . The nurse should do which of the following to assess for major symptoms associated with subdural hematoma? 1 Monitor the urine for blood. 2 Monitor the urinary output pattern. 3 Test for contractures of the extremities. 4 Test for equality of extremities when stimulating reflexes.

Answer: 4 Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the infant is actively bleeding.

A nurse is caring for a term infant who is 24 hours old who had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for further evaluation? 1 Weight loss of 4 ounces and dry, peeling skin 2 Blood glucose level of 40 mg/ dL before the last feeding 3 Breast-feeding for 20 minutes or more, with strong sucking 4 High-pitched cry, drinking 10 to 15 mL of formula per feeding

Answer: 4 Rationale: At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Blood glucose levels are acceptable at 40 mg/ dL during the first few days of life. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Breast-feeding for 20 minutes with a strong suck is an excellent finding. Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. Priority Nursing Tip: In the newborn, a low blood glucose level is prevented through early feedings.

A nurse in the delivery room assists with the delivery of a newborn infant. After delivery, the nurse prevents heat loss in the newborn infant resulting from conduction by: 1 Wrapping the newborn in a blanket 2 Closing the doors to the delivery room 3 Drying the newborn with a warm blanket 4 Placing a warm pad on the crib before placing the newborn in the crib

Answer: 4 Rationale: Hypothermia caused by conduction occurs when the newborn infant is on a cold surface, such as a cold pad or mattress. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Convection occurs as air moves across the newborn infant's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn infant radiates to a colder surface. Keeping the newborn infant dry by drying the wet newborn infant at birth will prevent hypothermia via evaporation. Priority Nursing Tip: Newborns do not shiver to produce heat . Instead , they have brown fat deposits, which produce heat.

A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, myelomeningocele type. Which nursing action is most important for the care for this infant? 1 Monitoring the temperature 2 Monitoring the blood pressure 3 Monitoring the specific gravity of the urine 4 Inspecting the anterior fontanel for bulging

Answer: 4 Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the gibbus and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.

A childbirth educator tells a class of expectant parents that it is standard routine to instill a medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum. The educator tells the class that the medication currently used for the prophylaxis of ophthalmia neonatorum is: 1 Vitamin K injection 2 Penicillin ophthalmic eye ointment 3 Neomycin ophthalmic eye ointment 4 Erythromycin ophthalmic eye ointment

Answer: 4 Rationale: Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X.

A nurse is monitoring a preterm newborn infant for signs of respiratory distress syndrome (RDS). The nurse monitors the infant for: 1 Acrocyanosis, emphysema, and interstitial edema 2 Acrocyanosis, apnea, pneumothorax, and grunting 3 Barrel-shaped chest, acrocyanosis, and bradycardia 4 Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring

Answer: 4 Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts . Acrocyanosis , the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life. Priority Nursing Tip: The presence of retractions indicates respiratory distress and possible hypoxemia.

The need for resuscitation of the newborn at risk can be anticipated if what risk factors are present? Select all that apply.

Multiple births difficult birth known congenital diaphragmatic hernia sepsis with cardiovascular collapse

The nurse should anticipate that the physiologic alterations of respiratory distress syndrome (RDS) can produce which of the following? Select all that apply.

RDS can cause hypoxia, respiratory acidosis, and metabolic acidosis.

In planning care for a newborn with polycythemis, the nurse would know that common symptoms of polycythemia include:

Tachycardia, respiratory distress, hyperbilirubinemia.

Coombs' test

The Coombs' test is performed to determine whether jaundice is due to Rh or ABO incompatibility. Actual blood type of the infant does not affect Coombs' testing, and hemoglobin and hematocrit testing will also not affect Coombs' tests. A left shift has to do with a complete blood count; a physician or practitioner would look at a left shift if considering sepsis as a diagnosis.

A nurse is assessing a 37-week gestation newborn born by cesarean section, and now at 4 hours of age on room air. The newborn had no breathing problems at birth. The nurse notes the following signs: expiratory grunting, flaring of the nares, mild cyanosis, and respirations of 120 bpm. The newborn is most likely experiencing:

Transient tachypnea of the newborn. This is a clear picture of how transient tachypnea of the newborn presents. In TTN, tachypnea is usually present by 6 hours of age, with respiratory rates as high as 100-140 bpm. It is more prevalent in cesarean births and near-term infants.

A physician or practitioner would order a Coombs' test in order to determine:

Whether jaundice is due to Rh or ABO incompatibility.

To obtain a blood specimen from the heel of a neonate, what intervention could a nurse perform to create adequate vasodilation? Select all that apply.

Wrap the foot in a warm washcloth. Apply warm diaper. Wrapping the foot in a warm washcloth or disposable diaper is a simple way to create adequate vasodilation for obtaining a blood specimen. Do not heat cloth in microwave; there may be hot spots that may burn the skin. Applying pressure to the heel may cause bruising to the neonate and alter the blood results. Venipuncture is rarely done; heel sticks are most common.

Neonatal risk factors for resuscitation are as follows:

nonreassuring fetal heart rate pattern; difficult birth; fetal scalp/capillary blood sample-acidosis; history of meconium in amniotic fluid; apneic episode; inadequate ventilation; male infant; prematurity; SGA; multiple births; structural lung abnormality; congenital heart disease; sepsis with cardiovascular collapse.