OB- Chapter 23

How do you prevent hypoglycemia?

-Provide early oral feedings within 1 hour after birth with breast milk/formula at frequent intervals (every 2-3 hours). -Monitor blood glucose levels via heel stick every hr for the first 4 hours of life, then every 3-4 hours until stable.

A nurse is providing care to a LGA newborn. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do first? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer

A) Administer intravenous glucose immediately.

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer

A) Administer intravenous glucose immediately.

What are some interventions done for a pre-term baby? SATA A) Breathing/respirations B) Temperature C) Feeding D) Glucose E) Bilirubin test

A) Breathing/respirations B) Temperature C) Feeding D) Glucose

After determining that a newborn is in need of resuscitation, the nurse would perform which action first? A) Dry the newborn thoroughly. B) Suction the airway. C) Administer ventilations. D) Give volume expanders

A) Dry the newborn thoroughly.

What are some interventions done for a post-term baby? SATA A) Feeding B) Glucose C) CBC D) Blood work

A) Feeding B) Glucose C) CBC

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. A) clustering care to promote rest B) positioning newborn in extension C) using kangaroo care D) loosely covering the newborn with blankets E) providing nonnutritive sucking

A) clustering care to promote rest C) using kangaroo care E) providing nonnutritive sucking

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which condition? A) retinopathy of prematurity B) metabolic acidosis C) infection D) cold stress

A) retinopathy of prematurity

A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? Select all that apply. A. poor sucking B. respiratory distress C. weak cry D. jitteriness E. blood glucose >40 mg/dl

A. poor sucking B. respiratory distress C. weak cry D. jitteriness Rationale: Some of the common problems associated with newborns experiencing a variation in gestational age, such as a post term newborn, are respiratory distress, jitteriness, feeble sucking, weak cry, and a blood glucose of 40 mg/dl. Reference: p. 846

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

Answer: 0.3 Rationale: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and ventilation. epinephrine: 1:10,000 concentration; 0.1 to 0.3 mL/kg IV; 3000 grams = 3 kg; 3 kg x 0.1 mL/kg = 0.3 mL; Question format: Fill in the Blank; Reference: p. 852-853

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

B) "We still need to monitor him closely for problems."

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which sign would the nurse be most likely to assess? A) increased respirations B) flaying hands C) eupnea D) increased heart rate

B) flaying hands

A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A. substance use disorder B. diabetes C. preeclampsia D. infection

B. diabetes Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth. Reference: p. 846

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which measure would the nurse be least likely to include in this plan? A) Stimulate the infant with frequent handling. B) Keep the newborn in an open bassinet. C) Administer oxygen using a oxygen hood. D) Give intermittent tube feedings

C) Administer oxygen using a oxygen hood.

A nurse is reviewing a journal article about newborn pain prevention and management. Which information would the nurse most likely find discussed in the article? A) Newborn pain is frequently recognized and treated. B) Newborns rarely experience pain with procedures. C) Pain is frequently mistaken for irritability or agitation. D) Newborns may be less sensitive to pain than adult

C) Pain is frequently mistaken for irritability or agitation.

The nurse is assessing a preterm newborn's fluid and hydration status. Which finding would alert the nurse to possible overhydration? A) decreased urine output B) tachypnea C) bulging fontanels D) elevated temperature

C) bulging fontanels

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose

D) Suction the mouth and then the nose

A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? A. bradycardia B. oxygen saturation level of 94% C. decreased muscle tone D. sudden high-pitched cry

D. sudden high-pitched cry Rationale: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone. Reference: p. 858

- Usually seen within the first few days after birth, manifested by yellow appearance of sclera and skin - > 12mg/dL - Excessive red cell hemolysis necessary to break down increased RBCs in circulation due to polycythemia - Resultant elevated bilirubin levels - Excessive bruising- from birth trauma adding to higher bilirubin levels

Hyperbilirubinemia

If untreated, high levels of unconjugated bilirubin may lead to kernicterus (neurologic syndrome that results in irreversible damage) with long-term sequelae that include cerebral palsy, sensorineural hearing loss, and mental retardation.

Hyperbilirubinemia

Effects of what condition cause the following : - < 40mg/dL - Low blood glucose= problematic during early post birth period b/c abrupt cessation of high-glucose maternal blood supply and continuation of insulin production by the newborn - Limited ability to release glucagon and catheholamines, which normally stimulate glucagon breakdown and glucose release. - Prolonged untreated- leads to serious, long-term adverse neurologic sequelae such as learning disabilities and retardation.

Hypoglycemia

Glucose is the major source of energy for organ function. Typical characteristics of this condition are: - Poor feedings - Jitteriness - Lethargy - High-pitched or weak cry - Apnea - Cyanosis and seizures - Some newborns are ASYMPTOMATIC

Hypoglycemia

This type of baby has: - Weigh more than 8 lb 13 oz - Can cause birth trauma - Requires interventions: BG, feeding, and phototherapy - Condition is due to gestational diabetes, postdates, and obesity

LGA- Large for gestational age

This type of baby is: - Born after 42 weeks gestation - Dry/peeling skin - Lots of creases in skin -Long, thin extremities, minimal fat - Loose skin around thighs/buttocks - Long overgrown fingernails - Meconium stained skin and fingernails - Thin umbilical cord - Has issues with feeding - Glucose issues - CBC - May have polycythemia

Post-term

This type of baby is: - Born prior to 37 weeks gestation - Is small - Has feeding issues - RDS- Respiratory distress syndrome

Pre-term

This type of baby has: - A large head - Weighs less than 5 lb 8 oz - Low body weight - Wasted appearance Complications with: - Respiratory - Temperature - BG - Jaundice - Polycythemia Interventions: warmth, CBC, and feeds.

SGA- Small for gestational age

A nurse is preparing a presentation for a group of perinatal nurses about common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the nurse includes which factor as contributing to the newborn's risk? Select all that apply. A) surfactant deficiency B) placental deprivation C) immaturity of the respiratory control centers D) decreased amounts of brown fat E) depleted glycogen stores

A) surfactant deficiency C) immaturity of the respiratory control centers

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A) small-for-gestational-age (SGA) newborns B) large-for-gestational-age (LGA) newborns C) appropriate-for-gestational-age (AGA) newborns D) low-birth-weight newborns

C) appropriate-for-gestational-age (AGA) newborns

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor? A) inability to clear fluids B) immature respiratory control center C) deficiency of surfactant D) smaller respiratory passages

C) deficiency of surfactant

A nurse is assessing a post term newborn. Which finding would the nurse correlate with this gestational age variation? A. moist, supple, plum skin appearance B. abundant lanugo and vernix C. thin umbilical cord D. absence of sole creases

C. thin umbilical cord Rationale: A post term newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet. Reference: p. 847

A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply. A. ruddy skin color B. respiratory distress C. cyanosis D. pink gums and tongue E. jitteriness

A. ruddy skin color B. respiratory distress C. cyanosis E. jitteriness Rationale: Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results. Reference: p. 846

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks' gestation. How would the nurse classify this newborn? A) preterm B) late preterm C) full term D) post-term

B) late preterm

A nurse is conducting a presentation for a group of pregnant women who are considered high-risk. After describing the complications that can occur in newborns, the nurse determines that the teaching was successful when the group identifies which newborn as having the lowest risk for problems? A) small-for-gestational-age B) large-for-gestational-age C) appropriate-for-gestational-age D) low-birthweight

C) appropriate-for-gestational-age

A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply. A. BMI 17.5 B. blood pressure 110/70 mm Hg C. prenatal history D. homelessness E. age F. prenatal care

A. BMI 17.5 C. prenatal history D. homelessness F. prenatal care Rationale: The key to identifying a newborn with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a newborn at risk. These factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of previous preterm birth. Reference: p. 840

A macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. For which would the nurse assess? Select all that apply. A. facial grimacing with movement B. bruising over area C. asymmetrical movement D. edema present E. positive Babinski reflex

A. facial grimacing with movement B. bruising over area C. asymmetrical movement D. edema present Rationale: Birth trauma for LGA newborns would be demonstrated by an obvious deformity, with bruising at the site and edema noted. There would be asymmetrical movement when the newborn moves the limb. Babinski reflex is a neurological test and would be normal to be positive. Reference: p. 846

A nurse is conducting a class for expectant parents about newborns. As part of the class the nurse describes newborns with birth-weight variations. The nurse identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? A) small for gestational age B) low birth weight C) very low birth weight D) extremely low birth weight

B) low birth weight

What are the newborn screening tests performed? SATA A) Hearing screen B) HIV screening C) PKU- for metabolic disorders D) CCHD- for congenital heart disorders

A) Hearing screen C) PKU- for metabolic disorders D) CCHD- for congenital heart disorders

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which findings would support the nurse's suspicion? Select all that apply. A) shallow, slow respirations B) cyanotic hands and feet C) irritability D) hypertonicity E) feeble cry

A) shallow, slow respirations B) cyanotic hands and feet E) feeble cry

A nurse is assessing a newborn who has been classified as small for gestational age. Which characteristics would the nurse expect to find? Select all that apply. A) wasted extremity appearance B) increased amount of breast tissue C) sunken abdomen D) adequate muscle tone over buttocks E) narrow skull sutures

A) wasted extremity appearance C) sunken abdomen E) narrow skull sutures

A client expresses concerns that her grandmothers had complicated pregnancies. What principle(s) should the nurse discuss to allay the fears of the client? Select all that apply. A. "We work to ensure that birth of high-risk infants happens in settings where we are able to care for them." B. "We will work with you to identify prenatal risk factors early and take actions to reduce their impact." C. "We support those at risk of having a preterm births with the goal of delaying early births." D. "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." E. "We allow families to grieve the loss of a newborn, should it occur."

A. "We work to ensure that birth of high-risk infants happens in settings where we are able to care for them." B. "We will work with you to identify prenatal risk factors early and take actions to reduce their impact." C. "We support those at risk of having a preterm births with the goal of delaying early births." D. "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." Rationale: The nurse will attempt to allay the client's fears by discussing the actions the facility enacts to promote a healthy birth and infant. This includes ensuring the birth of high-risk infants takes place in settings that have the technological capacity to care for them, identifying risk factors early and taking action to reduce their impact, working to delay the birth of those pregnancies identified at risk of preterm birth, and promoting an overall reduction in infant illness, disability, and death to proper care of the mother and infant. Although allowing a family to grieve in instances of infant death, discussing this factor with the client is likely to create more fear. Reference: p. 840

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply. A. Assess the axillary temperature every hour. B. Review maternal history. C. Assess environment for sources of heat loss. D. Bathe the neonate with warmer water. E. Minimize kangaroo care. F. Encourage skin-to-skin contact.

A. Assess the axillary temperature every hour. B. Review maternal history. C. Assess environment for sources of heat loss. F. Encourage skin-to-skin contact. Rationale: Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth. Reference: p. 842

A client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams). What priority assessment should be completed by the nurse? A. Blood glucose B. Temperature control C. Feeding difficulty D. Perfusion

A. Blood glucose Rationale: Hypoglycemia is a common concern with a large-for-gestational age (LGA) infant. This infant will deplete the glucose stores very rapidly. Therefore, it is important to assess the glucose level within 30 minutes of birth and to repeat every hour until stable. Hypoglycemia is defined as a glucose level less than 35 to 45 mg/dl (1.94 to 2.50 mmol/l) in the first 4 hours of life, and intervention should occur when the glucose is less than 40 mg/dl (2.22 mmol/l). Intervention should also occur if the blood glucose is less than 45 mg/dl (2.50 mmol/l) at 4 and 24 hours of life respectively. Generally the nurse assesses symptoms of jitteriness, irritability and tachypnea first. These symptoms can progress to temperature instability, lethargy, bradycardia, hyponia and seizures. Reference: p. 846

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply. A. Obtain hemoglobin and hematocrit laboratory tests B. Provide early feedings to prevent hypoglycemia C. Maintain oxygen saturation parameters D. Monitor urinary output E. Insert a peripheral IV

A. Obtain hemoglobin and hematocrit laboratory tests B. Provide early feedings to prevent hypoglycemia C. Maintain oxygen saturation parameters E. Insert a peripheral IV Rationale: Polycythemia in a neonate is defined as a hematocrit above 65% (0.65) and a hemoglobin level above 20 g/dl (200 g/l). The hematocrit and hemoglobin peak between 6 and 12 hours of life and then start to decrease. If these values do not decrease as expected, then hypoperfusion will occur and polycythemia will develop. In the beginning, the nurse may assess feeding difficulties, hypoglycemia, jitteriness and respiratory distress. As the condition worsens, a ruddy skin color could be seen, cyanosis could develop, the neonate could become lethargic and seizures could develop. Nursing care for this neonate requires obtaining hematocrit and hemoglobin laboratory tests at 2 hours, 12 hours and 24 hours. Feeding should be started to provide fluid, nutrition and prevent hypoglycemia. The oxygen saturation should be monitored. If the levels are below the established parameters from the health care provider, oxygen therapy will be needed. The urine output should be monitored continuously because polycythemia can cause real failure. A peripheral IV may or may not be needed. This would depend on the neonate's condition and if IV fluids would be required. Reference: p. 846

A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority? A. Preventing hypoglycemia with early feedings B. Observing for newborn reflexes C. Promoting bonding between the parents and the newborn D. Monitoring vital signs every 2 hours

A. Preventing hypoglycemia with early feedings Rationale: The nurse must consider the implications of a small-for-gestational-age newborn. With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for newborn reflexes, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn. Reference: p. 842

A term neonate has been admitted to the observational newborn nursery with the diagnosis of being small for gestational age. Which factors would predispose the neonate to this diagnosis? Select all that apply. A. The mother had chronic placental abruption. B. At birth the placenta was noted to be decreased in weight. C. On assessment the placenta had areas of infarction. D. At birth the placenta was a shiny Schultz presentation. E. Placental talipes was present at birth.

A. The mother had chronic placental abruption. B. At birth the placenta was noted to be decreased in weight. C. On assessment the placenta had areas of infarction. D. At birth the placenta was a shiny Schultz presentation. Rationale: Placental factors that can contribute to a small for gestational age infant include chronic placental abruption, infarction on surface of placenta, and a decreased placental weight. A shiny Schultz placenta is a normal description because the fetal side of the placenta comes out first, which is shiny. Placenta talipes does not exist. Reference: p. 841

A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine D. cyanosis E. Mongolian spots

A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine Rationale: Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice. Reference: p. 862

A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A. ophthalmologist B. nephrologist C. cardiologist D. neurologist

A. ophthalmologist Rationale: Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity (ROP) and further respiratory complications in the preterm newborn (Martin & Deakins, 2020). For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. As a result, an ophthalmology consult for follow-up after discharge is essential for preterm infants who have received extensive oxygen. Although referrals to other specialists may be warranted depending on the newborn's status, there is no information to suggest that any would be needed. Reference: p. 854

A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? Select all that apply. A. the age of the client B. living in a shelter for victims of intimate partner violence C. vaginal bleeding D. fetal heart rate E. blood pressure F. positive test for TORCH

A. the age of the client B. living in a shelter for victims of intimate partner violence C. vaginal bleeding E. blood pressure F. positive test for TORCH Rationale: Some factors contributing to the birth of SGA newborns include maternal age of 20 or 35 years old, low socioeconomic status, and preeclampsia with increased blood pressure. The vaginal bleeding indicates placental problems, and she tests positive for sexually transmitted diseases by TORCH group infections. Reference: p. 840

A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? A. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish." B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." C. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." D. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."

B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." Rationale: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours. Reference: p. 862

A set of newborn twins has been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply. A. hemoglobin 15 g/dl (150 g/l) B. A1C levels of 8% (0.08) C. heroin use disorder D. blood pressure baseline of 170/90 mm Hg E. age 39 years F. multiple gestation

B. A1C levels of 8% (0.08) C. heroin use disorder D. blood pressure baseline of 170/90 mm Hg E. age 39 years F. multiple gestation Rationale: Assessment of the small-for-gestational-age (SGA) or FGR infant begins by reviewing the maternal history to identify risk factors such as maternal age over 30 years, a substance use disorder, hypertension, multiple gestation. Gestational diabetes or diabetes mellitus is also a factor. Normal A1C level is 5.7% (0.57) for a person without diabetes. Hemoglobin is normal for pregnant woman in third trimester. Reference: p. 841

A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. A. Advise the parents that the hospital can make the arrangements. B. Offer to pray with the family if appropriate. C. Leave the parents to talk through their next steps. D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness.

B. Offer to pray with the family if appropriate. D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness. Rationale: When assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family's spiritual needs and readiness. The nurse will also initiate spiritual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate. Reference: p. 863

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A. Avoid using the terms "death" or "dying." B. Provide opportunities for them to hold the newborn. C. Refrain from initiating conversations with the parents. D. Quickly refocus the parents to a more pleasant topic.

B. Provide opportunities for them to hold the newborn. Rationale: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process. Reference: p. 847

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant? A. The neonate is average for its gestational age. B. The neonate is small for its gestational age. C. The neonate is large for its gestational age. D. The neonate is fetal growth restricted.

B. The neonate is small for its gestational age. Rationale: Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology. Reference: p. 840-841

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding? A. Conduction heat loss is a problem in the baby. B. The supply of brown adipose tissue is not developed. C. Axillary temperatures are not accurate. D. This is a normal temperature.

B. The supply of brown adipose tissue is not developed. Rationale: Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates. Reference: p. 855

The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. strong, brisk motor skills B. difficulty in arousing to a quiet alert state C. birthweight of 7 lb, 14 oz (3,572 g) D. wasted appearance of extremities

B. difficulty in arousing to a quiet alert state Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb, 13 oz (3,997 g) at term. Reference: p. 846

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: A. preterm. B. late preterm. C. term. D. post term.

B. late preterm. Rationale: Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a post term newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation. Reference: p. 847

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Reassure them that their newborn is progressing well. C. Encourage the parents to touch their preterm newborn. D. Discuss the care they will be giving the newborn upon discharge.

C. Encourage the parents to touch their preterm newborn. Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated. Reference: p. 857

A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply. A. There is flaccid muscle tone of the affected limb. B. Respiration rate is 52 breaths per minute. C. Heart rate is 180 beats per minutes. D. Oxygen saturation level is 88%. E. The infant has facial grimacing and quivering chin.

C. Heart rate is 180 beats per minutes. D. Oxygen saturation level is 88%. E. The infant has facial grimacing and quivering chin. Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the normal blood pressure, pulse, and respiration are noted. Reference: p. 858

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) "I'll be here to help you all along the way." B) "What has helped you to deal with stressful situations in the past?" C) "Let me tell you about what you will see when you visit your baby." D) "Forget about what's happened in the past, and focus on the now."

D) "Forget about what's happened in the past, and focus on the now."

Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretions. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next? A. Intubate with an appropriate-sized endotracheal tube. B. Give chest compressions at a rate of 80 times per minute. C. Administer epinephrine intravenously. D. Clear the airway with a bulb syringe.

D. Clear the airway with a bulb syringe. Rationale: After placing the newborn's head in a neutral position, the nurse would clear the airway with a bulb syringe or suction. This is followed by assessment of breathing and bagging if needed, placing a pulse oximeter, ventilating the newborn, assessing the heart rate and giving chest compressions if needed, and then administering epinephrine and/or volume expansion if needed. Reference: p. 852-853

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. fewer visible blood vessels through the skin B. more subcutaneous fat in the neck and abdomen C. well-developed flexor muscles in the extremities D. greater body surface area in proportion to weight

D. greater body surface area in proportion to weight Rationale: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone. Reference: p. 855

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as: A. cardiac distress. B. respiratory alkalosis. C. bronchial pneumonia. D. respiratory distress.

D. respiratory distress. Rationale: Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time. Reference: p. 852-853