[OB-2] Chapter 26 - The Newborn at Risk: Conditions Present at Birth

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. The nurse's best response is: 1. "Most newborns are nose breathers." 2. "The tube will elicit the sucking reflex." 3. "A smaller catheter is preferred for feedings." 4. "Most newborns are mouth breathers."

Correct Answer: 1 Rationale 1: Most newborns are nose breathers; therefore, an orogastric catheter is preferable. Rationale 2: Gavage feedings are used when newborns have a poorly coordinated suck or swallow reflex, or are ill. Rationale 3: A small catheter is used for a nasogastric tube to minimize airway obstruction. Rationale 4: Most newborns are nose breathers; therefore, an orogastric catheter is preferable.

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? 1. Offer more frequent feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth.

Correct Answer: 1 Rationale 1: Newborns of diabetic mothers can require more frequent feedings. Rationale 2: If the newborn's blood sugar level falls below 45 mg/dl, and if normal levels cannot be maintained by early feedings of formula or breast milk, the newborn might require intravenous infusions of D10W, along with oral feedings, to maintain normoglycemia. Rationale 3: The newborn should be assessed for hypocalcemia. Rationale 4: Hyperbilirubinemia can occur 48-72 hours after birth.

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dl. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia.

Correct Answer: 1 Rationale 1: Newborns of diabetic mothers whose blood glucose falls below 45 mg/dl should have early feedings with formula or breast milk. Rationale 2: If normal levels of glucose cannot be maintained, the newborn might require intravenous infusions of D10W, along with oral feedings, to maintain normoglycemia. Rationale 3: The onset of hypoglycemia occurs 1-3 hours after birth. Blood glucose levels should be checked hourly during the first 4 hours and then at 4-hour intervals until the risk peak has passed. Rationale 4: Hypothermia is more common in SGA newborns, due to diminished subcutaneous fat.

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.

Correct Answer: 1 Rationale 1: Newborns with fetal alcohol syndrome have feeding problems and are prone to heat loss; therefore, extra time and patience are needed for feeding. Rationale 2: Staff consistency is important when working with the newborn. Rationale 3: Environmental stimuli should be kept to a minimum. Rationale 4: Newborns with fetal alcohol syndrome are prone to heat loss.

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for: 1. Visual impairment. 2. Hypercalcemia. 3. Cerebral palsy. 4. Sensitive gag reflex.

Correct Answer: 1 Rationale 1: Premature infants are at greater risk for developing complications related to prolonged oxygen therapy, such as retinopathy, which can lead to visual impairment. Rationale 2: Hypocalcemia is more common in premature infants. Rationale 3: Cerebral palsy can be caused by decreased oxygen. Rationale 4: An absent or decreased gag reflex is more common in premature infants.

The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. Teaching includes information about: 1. Specially prepared formulas. 2. Cataract problems. 3. Respiratory problems. 4. Administration of thyroid medication.

Correct Answer: 1 Rationale 1: Teaching should include information about special diets that limit intake of phenylalanine. Special formulas low in phenylalanine include Lofenalac, Minafen, and Albumaid XP. Rationale 2: Cataracts are associated with infants who have galactosemia. Rationale 3: If treatment is begun before 1 month of age, CNS damage can be minimized in the PKU infant. Rationale 4: Thyroid medication is given to infants with congenital hypothyroidism.

The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? 1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."

Correct Answer: 1 Rationale 1: Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. Deoxygenated blood is shunted from the right ventricle through the VSD into the left ventricle, bypassing the lungs and circulating de-oxygenated blood. Rationale 2: This describes coarctation of the aorta, which is not a cyanotic heart defect but an obstructive defect to systemic blood flow. Rationale 3: This describes transposition of the great vessels. Rationale 4: This describes hypoplastic left heart syndrome.

The nurse is caring for several pregnant patients. Which patient should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old G8 P2323, works in a chemical factory 2. 23-year-old primip, low socioeconomic status, unmarried 3. 16-year-old primip, began prenatal care at 30 weeks. 4. 28-year-old G2 P1001, history of gestational diabetes

Correct Answer: 1 Rationale 1: This patient is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. Rationale 2: The main risk factor for this patient is her low socioeconomic status. Rationale 3: This patient has two risk factors: young age and late onset of prenatal care. Rationale 4: This patient's only risk factor is the history of gestational diabetes.

The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? 1. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." 2. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."

Correct Answer: 1 Rationale 1: This statement is correct. Rationale 2: Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. Rationale 3: Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. Rationale 4: Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue.

The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a blood calcium level. 2. Take the newborn's temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.

Correct Answer: 1 Rationale 1: Tremors are the classic sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. Rationale 2: Body temperature might be necessary to monitor, but another action takes priority for this newborn. Rationale 3: Bilirubin level might be necessary to monitor, but another action takes priority for this newborn. Rationale 4: Oxygen saturation might be necessary to monitor, but another action takes priority for this newborn.

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Volume of urine output. 2. Weight. 3. Blood pH. 4. Head circumference. 5. Bowel sounds.

Correct Answer: 1,2 Rationale 1: In order to assess hydration status, volume of urine output must be evaluated. Rationale 2: In order to assess hydration status, the infant's weight must be evaluated. Rationale 3: Blood pH is not an indicator of hydration. Rationale 4: Head circumference is not an indicator of hydration. Rationale 5: Bowel sounds are not an indicator of hydration.

Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Diaphoresis 5. Tachypnea

Correct Answer: 1,2,4,5 Rationale 1: Reduced oxygenation saturation, related to unoxygenated blood entering the systemic circulation without entering the lungs, accounts for the cyanosis or blue coloration of the skin. Cyanosis indicates a possible cardiac defect. Rationale 2: Heart murmur is abnormal extra heart sounds caused by shunting of the blood. Rationale 3: The signs of congestive heart failure include tachycardia, not bradycardia. Rationale 4: The signs of congestive heart failure include diaphoresis, which is often seen on the head during exertion. Rationale 5: The signs of congestive heart failure include tachypnea, which is a respiratory rate greater than 60 breaths/min and which occurs in response to decreased lung compliance.

The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a sheepskin in pillow under the head.

Correct Answer: 1,2,4,5 Rationale 1: The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day. Rationale 2: The infant has congenital hydrocephalus. Increased bulging and widening of sutures indicate increased intracranial pressure. Rationale 3: The infant's position should be changed frequently to maintain skin integrity. Rationale 4: Infants with hydrocephalus are prone to infection. Rationale 5: The infant has congenital hydrocephalus. The enlarged head should be supported with soft sheepskin to prevent skin breakdown.

The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.

Correct Answer: 1,3,4 Rationale 1: The nurse should instruct the parents on proper hand-washing technique. Rationale 2: Small, frequent meals are recommended. Rationale 3: The nurse should instruct the parents on proper disposal of soiled diapers. Rationale 4: The nurse should instruct the parents on how to cleanse the diaper changing area with a bleach solution after each diaper change Rationale 5: Taking rectal temperatures is to be avoided because it could stimulate diarrhea.

The nurse is caring for a prenatal patient. Reviewing the patient's pregnancy history, the nurse identifies risk factors for an at-risk newborn, including: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The mother's low socioeconomic status. 2. Maternal age of 26. 3. Mother's exposure to toxic chemicals. 4. More than three previous deliveries. 5. Maternal hypertension.

Correct Answer: 1,3,4,5 Rationale 1: Low income or educational level is associated with low-birth-weight infants and intrauterine growth retardation. Rationale 2: This age is not a risk factor. Rationale 3: Environmental hazards are associated with low birth weight, decreased placental perfusion, IUGR, and congenital anomalies. Rationale 4: Multiparity greater than three is associated with increased risk of fetal death, IUGR, anemia, and hypoxia. Rationale 5: Preexisting maternal conditions such as hypertension are a risk factor.

The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Note: Credit will be given if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma

Correct Answer: 1,3,4,5 Rationale 1: Tremors are the obvious clinical sign of hypocalcemia. Rationale 2: Hypoglycemia is often evident rather than hyperglycemia. Rationale 3: Hyperbilirubinemia is caused by slightly decreased extracellular fluid volume, which increases the hematocrit level. Rationale 4: Respiratory distress syndrome occurs when insulin antagonizes the cortisol-induced stimulation of lecithin synthesis that is necessary for lung maturation. Rationale 5: Trauma can occur during labor and birth from shoulder dystocia.

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Depressed respiratory effort 5. Transient tachypnea

Correct Answer: 1,3,5 Rationale 1: Newborns born to drug-addicted mothers exhibit hyperirritability. Rationale 2: Newborns born to drug-addicted mothers show increased, not decreased, muscle tone. Rationale 3: Newborns born to drug-addicted mothers exhibit exaggerated reflexes. Rationale 4: Newborns born to drug-addicted mothers do not exhibit depressed respiratory effort. Rationale 5: Newborns born to drug-addicted mothers exhibit transient tachypnea.

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with an anti-HIV-1 antibody assay at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4-5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child.

Correct Answer: 2 Rationale 1: Eight months is too early for this test. The HIV-1 antibody assay becomes accurate at 15-18 months of age, after the maternal antibodies have cleared from the infant's system. Rationale 2: Prophylactic medication helps reduce the risk of vertical transmission from exposure to maternal blood and body fluids at birth. The dose for term newborns is 2 mg/kg/dose PO every 6 hours. Rationale 3: GI problems-including lack of weight gain, weight loss, and wasting-are common with HIV-positive infants. Small, frequent feedings are best tolerated and facilitate optimal growth and weight gain. Large feedings should be avoided. Rationale 4: Breastfeeding is contraindicated for HIV-positive mothers because breast milk has been shown to contain the virus. Bottle-feeding is the recommended feeding method.

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? 1. "This condition occurs more frequently among Japanese people." 2. "We must be very careful to avoid most proteins, to prevent brain damage." 3. "Carbohydrates can cause our baby to develop cataracts and liver damage." 4. "Our baby's thyroid gland isn't functioning properly."

Correct Answer: 2 Rationale 1: Japanese people have a very low rate of PKU disease; it is most common among northern Europeans. Rationale 2: PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. High phenylalanine levels cause brain damage and severe neurologic abnormalities. Rationale 3: Galactosemia is the disease that is a carbohydrate metabolism problem. Rationale 4: Congenital hypothyroidism is the disorder of low thyroid function at birth.

An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? 1. Do not add food supplements to the baby's diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Put the infant in sunlight through a window.

Correct Answer: 2 Rationale 1: Small, frequent feedings are recommended, as well as food supplementation as necessary to support weight gain. Rationale 2: The nurse should instruct the parents about proper hand-washing techniques, about proper disposal of soiled diapers, and to wear gloves when diapering. Rationale 3: Soiled linens should be washed in hot, sudsy water with bleach. Rationale 4: Placing an infant in sunlight through a window is recommended for jaundice, not HIV exposure.

Which nursing diagnoses would the nurse apply to a newborn exposed to HIV/AIDS? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Altered Nutrition: More than Body Requirements 2. Risk for Impaired Skin Integrity 3. Risk for Infection 4. Impaired Physical Mobility 5. Sleep Pattern Disturbance

Correct Answer: 2,3,4 Rationale 1: The correct diagnosis would be Less than Body Requirements related to formula intolerance and inadequate intake. Rationale 2: Risk of impaired skin integrity is related to chronic diarrhea. Rationale 3: Risk for infection is related to perinatal exposure and immunoregulation suppression secondary to HIV/AIDS. Rationale 4: Impaired physical mobility is related to decreased neuromuscular development. Rationale 5: This diagnosis is pertinent to the newborn who is drug-exposed, related to CNS excitation secondary to drug withdrawal.

A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights.

Correct Answer: 2,3,5 Rationale 1: Care should be clustered to minimize the number of times the newborn is disturbed. Rationale 2: Silencing alarms quickly is an intervention that can support development in a preterm newborn. Rationale 3: Placing a blanket over the top portion of the incubator can support development in a preterm newborn. Rationale 4: Pacifiers can be offered because they provide opportunities for non-nutritive sucking. Rationale 5: Dimming the lights is an intervention that can support development in a preterm newborn.

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Unrelieved irritability 4. Positive Babinski's reflex

Correct Answer: 3 Rationale 1: An occasional watery stool can be associated with the normal newborn. Rationale 2: Spitting up after some feedings can be associated with the normal newborn. Rationale 3: Unrelieved irritability can be an indicator of drug withdrawal. Rationale 4: A positive Babinski's reflex can be associated with the normal newborn.

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to: 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.

Correct Answer: 3 Rationale 1: Drug-dependent newborns are at a greater risk for SIDS. Therefore, the newborn should sleep in a supine position. Rationale 2: Small, frequent feedings are recommended. Rationale 3: Drug-dependent newborns are at a greater risk for SIDS. Therefore, the newborn should sleep in a supine position, and a home apnea-monitoring system should be installed. Rationale 4: A pacifier may be offered to provide non-nutritive sucking.

The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. All of the following assessment findings are congruent with prematurity except: 1. Cry is weak and feeble. 2. Clitoris and labia minora are prominent. 3. Strong sucking reflex. 4. Lanugo is plentiful.

Correct Answer: 3 Rationale 1: Findings that indicate prematurity include a weak cry. Rationale 2: Findings that indicate prematurity include a prominent clitoris and labia minora. Rationale 3: A strong sucking reflex is found in normal term newborns. Rationale 4: Findings that indicate prematurity include lanugo that is plentiful and widely distributed.

The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR

Correct Answer: 3 Rationale 1: Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. Symmetrical IUGR would have head circumference below the 10th percentile. Rationale 2: Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. Rationale 3: The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. Rationale 4: The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is considered small for gestational age.

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Risk for Impaired Elimination 2. Risk for Ineffective Airway Clearance 3. Impaired Oxygenation 4. Enhanced Family Coping

Correct Answer: 3 Rationale 1: Impaired elimination can develop if necrotizing fasciitis develops, but is not the highest priority. Rationale 2: Ineffective airway clearance can be an issue for preterm infants due to weak respiratory muscles, but is not the highest priority. Rationale 3: Oxygenation is an issue with preterm infants secondary to lung immaturity, and has the highest priority. Rationale 4: Family coping is a psychosocial need, and is therefore a lower priority than are physiologic needs.

The nurse is preparing to gavage-feed a preterm infant. Put the steps in the correct order, creating a five-digit number. Standard Text: Click and drag the options below to move them up or down. Choice 1. Check pH of the gastric aspirate. Choice 2. Elevate the syringe 6-8 inches above the infant's head. Choice 3. Measure from the tip of the nose to the earlobe to the xyphoid process. Choice 4. Clear the tubing with 2-3 ml of sterile water. Choice 5. Lubricate the tube by dipping it into sterile water.

Correct Answer: 3,4,1,5,2 Rationale 1: 1. This step is undertaken after the tube has been inserted to verify correct placement of the tube. 2. This step allows gravity to create a gradual flow of the feeding.3. This is the first step, and determines the appropriate length of the tube to be inserted. 4. After the formula or breast milk has flowed into the stomach through the tube, the tube is cleared to prevent aspiration of the feeding if leakage takes place as the tube is withdrawn.5. After the length of tube to be inserted is determined, the tube is lubricated by dipping it into water to facilitate passage through the nose. Rationale 2: 1. This step is undertaken after the tube has been inserted to verify correct placement of the tube. 2. This step allows gravity to create a gradual flow of the feeding.3. This is the first step, and determines the appropriate length of the tube to be inserted. 4. After the formula or breast milk has flowed into the stomach through the tube, the tube is cleared to prevent aspiration of the feeding if leakage takes place as the tube is withdrawn.5. After the length of tube to be inserted is determined, the tube is lubricated by dipping it into water to facilitate passage through the nose. Rationale 3: 1. This step is undertaken after the tube has been inserted to verify correct placement of the tube. 2. This step allows gravity to create a gradual flow of the feeding.3. This is the first step, and determines the appropriate length of the tube to be inserted. 4. After the formula or breast milk has flowed into the stomach through the tube, the tube is cleared to prevent aspiration of the feeding if leakage takes place as the tube is withdrawn.5. After the length of tube to be inserted is determined, the tube is lubricated by dipping it into water to facilitate passage through the nose. Rationale 4: 1. This step is undertaken after the tube has been inserted to verify correct placement of the tube. 2. This step allows gravity to create a gradual flow of the feeding.3. This is the first step, and determines the appropriate length of the tube to be inserted. 4. After the formula or breast milk has flowed into the stomach through the tube, the tube is cleared to prevent aspiration of the feeding if leakage takes place as the tube is withdrawn.5. After the length of tube to be inserted is determined, the tube is lubricated by dipping it into water to facilitate passage through the nose. Rationale 5: 1. This step is undertaken after the tube has been inserted to verify correct placement of the tube. 2. This step allows gravity to create a gradual flow of the feeding.3. This is the first step, and determines the appropriate length of the tube to be inserted. 4. After the formula or breast milk has flowed into the stomach through the tube, the tube is cleared to prevent aspiration of the feeding if leakage takes place as the tube is withdrawn.5. After the length of tube to be inserted is determined, the tube is lubricated by dipping it into water to facilitate passage through the nose.

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "Our baby will be in an isolette to keep him warm." 2. "Breathing might be harder for our baby because he is early." 3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days."

Correct Answer: 3,4,5 Rationale 1: Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An isolette or overhead warmer is used to keep the baby warm. Rationale 2: Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants. Rationale 3: Preterm infants grow more slowly than do term infants. Rationale 4: Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. Rationale 5: Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine.

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Acrocyanosis 4. Cyanosis of the buccal membranes

Correct Answer: 4 Rationale 1: An apical heart rate of 140 is a normal assessment finding for newborns. Rationale 2: A respiratory rate of 40 is a normal assessment finding for newborns. Rationale 3: Acrocyanosis (cyanosis of the extremities) is a normal assessment finding for newborns. Rationale 4: Cyanosis of the buccal membranes is not a normal finding in a newborn, and could indicate a congenital heart defect.

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? The new nurse: 1. Holds the infant after giving a gavage feeding. 2. Auscultates lung sounds bilaterally. 3. Provides care when the baby is awake. 4. Gives the feeding with room-temperature formula.

Correct Answer: 4 Rationale 1: If the infant cannot be held during a feeding, she should be held after feedings for comfort. Rationale 2: Bilateral auscultation is important. Rationale 3: Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible. Rationale 4: Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature.

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dl. The best nursing action is to: 1. Recheck the blood sugar in 4 hours. 2. Begin an IV of 10% dextrose. 3. Feed the baby 1 ounce of formula. 4. Document the findings in the chart.

Correct Answer: 4 Rationale 1: Infants of diabetic mothers should be fed frequently, and should have their blood sugar assessed frequently. Four hours is too long a time frame. Rationale 2: A blood sugar reading of 47 mg/dl is considered normal for a neonate. No IV is needed. Rationale 3: Feeding would be appropriate if the infant's blood sugar were below 45 mg/dl, but this infant's reading is 47. Rationale 4: A blood sugar level of 47 mg/dl is a normal finding; documentation is an appropriate action.

A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment.

Correct Answer: 4 Rationale 1: LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, and can have feeding difficulties. Rationale 2: LGA, not SGA, newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic disproportion. Rationale 3: SGA newborns are more prone to hypoglycemia. Rationale 4: Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss.

The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with: 1. Oomphalocele. 2. Gastroschisis. 3. Diaphragmatic hernia. 4. Myelomeningocele.

Correct Answer: 4 Rationale 1: Oomphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental. Rationale 2: Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs' being located on the outside of the body. Positioning on the abdomen would be detrimental. Rationale 3: Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in the bowel and sometimes the stomach's extending upward through the defect and into the chest cavity. Rationale 4: Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present.

The nurse caring for a postterm newborn would not perform the intervention of: 1. Providing warmth. 2. Frequently monitoring blood glucose. 3. Observing respiratory status. 4. Restricting breastfeeding.

Correct Answer: 4 Rationale 1: Provision of warmth is an important intervention for postterm newborns. Rationale 2: Frequent monitoring of blood glucose is an important intervention for postterm newborns. Rationale 3: Observation of respiratory status is an important intervention for postterm newborns. Rationale 4: Breastfeeding is encouraged in the care of postterm newborns.

Parents have been told their child has fetal alcohol syndrome. Which statement by a parent indicates that additional teaching is required? 1. "Our baby's heart murmur is from this syndrome." 2. "He might be a fussy baby because of this." 3. "His face looks like it does due to this problem." 4. "Cuddling and rocking will help him stay calm."

Correct Answer: 4 Rationale 1: Ventral and atrial septal defects are common in babies with FAS. Rationale 2: FAS babies are easily overstimulated, and have feeding difficulties, leading to more crying than seen in an average baby. Rationale 3: Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes, small chin, and smooth philtrum. Rationale 4: FAS babies are easily overstimulated, and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm.