The neonate Passpoint

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse?

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

The nurse is teaching a group of new parents about car seat safety. The nurse would know education has been effective when a parent makes which statement?

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

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?

Correct response: "The vernix indicates a different gestational age than expected." Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond?

Correct response: "They're normal and will disappear as the baby's skin thickens." Explanation: Capillary hemangioma (also called a "stork bite") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and will disappear as the skin thickens. They are not associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands.

A new parent asks, "When will the soft spot near the front of my baby's head close?" When should the nurse tell the parent the soft spot will close?

Correct response: 12 to 18 months Explanation: Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniosynostosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.

While performing an assessment, the nurse notes the infant's jaundice has moved from the nipple line to the umbilicus in the past 24 hours. How does the nurse interpret this physical finding?

Correct response: An increase in bilirubin level is probable. Explanation: Jaundice progresses in a cephalocaudal manner. The jaundice increased from the nipple line to the umbilicus, which indicates that the bilirubin levels are increasing in this infant. Continued assessment is necessary to monitor the rise in bilirubin levels with the potential need for phototherapy to prevent possible kernicterus.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism?

Correct response: Chlamydia trachomatis Explanation: The use of erythromycin ophthalmic ointment prevents blindness from gonococcal organisms and C. trachomatis. This ointment usually is less expensive than tetracycline.Beta-hemolytic streptococcus, E. coli, and S. aureus can cause a generalized infection in the neonate. However, these organisms typically are not responsible for causing neonatal blindness.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first?

Correct response: Clear the neonate's airway with suction or gravity. Explanation: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction.Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway.Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway.Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged, causing further breathing difficulties.

On examination of a newborn client, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which nursing action is appropriate?

Correct response: Consider the finding as normal. Explanation: The nurse should consider the pigmented area as normal. These are called flat gray nevi (formerly called Mongolian spots), which are clusters of melanocytes. Most moles in children are junctional nevi—flat, well demarcated, brown to bluish black—that can appear anywhere on the skin. Asking the maternal parent about complications in pregnancy, informing the health care provider about the condition, and putting a dressing over the pigmented area are inappropriate responses because the finding is normal.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?

Correct response: Continue feeding every 3 to 4 hours since the weight loss is normal. Explanation: This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle feeding, the neonate's intake varies from one feeding to another. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the HCP should be called.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?

Correct response: Deficient knowledge related to lack of exposure to apnea monitor. Explanation: For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after birth but would probably be resolved by the time the neonate is ready for discharge.

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?

Correct response: Do nothing — acrocyanosis is normal in the neonate. Explanation: Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. Activating the code emergency response system, taking the neonate's temperature, and notifying the physician that a cardiac consult is needed are inappropriate actions.

The heart rate of a newly born term neonate is regular at 142 bpm. What should the nurse do next?

Correct response: Document this as a normal neonatal finding. Explanation: Normally, a neonate's heart rate should be between 120 and 160 bpm shortly after birth. The nurse should document this as a normal neonatal finding. The HCP does not need to be notified. Assessing for cyanosis is a routine assessment at birth, but with the neonate's heart rate at 142 bpm, cyanosis should be minimal and typically located in the hands and feet. Heart rate assessments are performed routinely according to facility protocol. For example, the heart rate is assessed soon after birth, every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then every 4 hours.

The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Correct response: Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established.Bottle supplements are not appropriate to prevent jaundice, though if the neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding.Breastfeeding is considered the best nutritional source for infants.Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were planning to breastfeed the neonate. Which instructions about breastfeeding would be mostappropriate?

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

After a long labor process, a primigravid client gives birth to a healthy newborn with a moderate amount of skull molding. What information would the nurse include when explaining to the client about this condition?

Correct response: It usually lasts a day or two before resolving. Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a long labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

Correct response: Keep the neonate's eyes completely covered. Explanation: To prevent eye damage from phototherapy, the eyes must remain covered at all times while under the lights. The eye patches can be removed when the neonate is held out of the lights by the parents for feeding. Instead of a regular diaper, a "string" diaper or disposable face mask may be used to help contain loose stools, while allowing maximum skin exposure. Feeding formula or breast milk every 2 to 3 hours is recommended to prevent hypoglycemia and to encourage gastrointestinal motility. Because the phototherapy lights can overheat the neonate, the temperature should be checked by the axillary route every 2 to 4 hours.

When the nurse accidentally bumps the bassinet, the neonate throws out their arms, opens their hands, and begins to cry. The nurse interprets this reaction as indicative of which reflex?

Correct response: Moro reflex Explanation: The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.The Babinski reflex is elicited by stroking the neonate's foot resulting in the fanning of the toes. This reflex is normal in the neonate until approximately 3 months of age.The grasping reflex is demonstrated when the neonate grasps an object placed in the hand.The tonic neck reflex (or fencing reflex) is demonstrated when the neonate, lying supine, turns the head to one side.

A primiparous client expresses concern to the nurse about why their neonate's eyes are crossed. Which information would the nurse include when teaching the parent about neonatal strabismus?

Correct response: Neonates commonly lack eye muscle coordination. Explanation: Convergent strabismus is common during infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fixate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light. However, this is not associated with strabismus. An absent red reflex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is mostappropriate?

Correct response: Notify the health care provider (HCP) immediately. Explanation: A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the HCP immediately. The HCP should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?

Correct response: Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact. Explanation: The normal axillary temperature range for a neonate is 97.7 to 99.5°F (36.5 to 37.5°C). A temperature of 97.3°F (36.3°C) is slightly below normal. Because the neonate is full-term, it is safe to warm the neonate using conservative measures such as placing a cap on the head and trying skin-to-skin contact. There is no need to encourage feeding. Performing an assessment would require exposing the neonate and is not indicated. If this were an unstable or preterm neonate, an incubator may be recommended due to the underdeveloped thermoregulation in these neonates. Neonates with hypothermia experience bradycardia, which is defined as a heart rate less than 100 beats/minute.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); the baby is breathing room air and is pink with acrocyanosis. The birth parent had membranes that were ruptured 26 hours before birth. What nursing action is most indicated?

Correct response: Place a pulse oximeter, and request a prescription to draw blood cultures. Explanation: The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate higher than 60 breaths/min, grunting, and occasional flaring are not normal. Although these findings are not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during the first 24 hours?

Correct response: Provide frequent early feedings with formula. Explanation: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Correct response: Request that the health care provider evaluate the neonate's neurologic status. Explanation: Typically a neonate's cry is loud and lusty. A weak, shrill, or high-pitched cry is not normal, possibly indicating a neurologic problem, such as increased intracranial pressure, infection, or hypoglycemia. Thus, the nurse should request that the health care provider evaluate the neonate.Telling the birth mother that the cry is due to excessive analgesia in labor is not warranted. Stimulating the neonate to cry is not helpful because the cry is most likely due to an underlying problem.Continuing to monitor the infant is a routine nursing responsibility that may be helpful if the neonate needs to be treated for a neurologic problem or drug withdrawal. However, the health care provider needs to be notified first.

The nurse is teaching the parent of a newborn to develop their baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the parent to perform which action?

Correct response: Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple. Explanation: Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn the eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.

While caring for a client and their 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains the neonate's need for gavage feeding at this time instead of the client's plan for bottle-feeding. What should the nurse include as the rationale for this feeding plan?

Correct response: The neonate has difficulty coordinating sucking, swallowing, and breathing. Explanation: Before 32 weeks' gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle-feeding. Bottle-feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feeding prevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment.

When developing the plan of care for a neonate, the nurse should include what measure to prevent heat loss from conduction?

Correct response: Warm the stethoscope before using it. Explanation: Because a neonate has poor thermal stability, reducing heat loss is very important. Conductioninvolves the loss of heat to a cooler surface by direct skin contact. Cold stethoscopes, cold hands, and cold scales can all cause heat loss by conduction. Therefore, warming the stethoscope before using it would be appropriate.Drying the neonate with sterile towels prevents heat loss from evaporation, the loss of heat when water is converted to a vapor.Keeping the neonate away from windows prevents heat loss from radiation. Radiation losses occur when heat is transferred from a heated body surface to a cooler solid object that is not in direct contact with the body.Administering warm oxygen prevents heat loss from convection, loss of heat from the warm body surface to cooler air currents.

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material has which characteristic?

Correct response: a curdled appearance Explanation: Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and it occurs during or immediately after feeding.Vomiting is unrelated to feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 ml.Vomited material is typically white and curdled in appearance. A brownish color suggests old blood.Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The neonate's parents ask the nurse what this score indicates. Which explanation is appropriate for the nurse to give the parents?

Correct response: a neonate who's in good condition Explanation: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would mostsuggest the infant is developing necrotizing enterocolitis (NEC)?

Correct response: abdominal distention Explanation: Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?

Correct response: adduction and flexion of the extremities with gently rounded shoulders Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

A neonate is being discharged to a home with a multigenerational family. The neonate will primarily be cared for by a grandparent with assistance from the parents, who are the neonate's legal guardians, and an adolescent sibling of the neonate. Who should the nurse provide education to before discharge?

Correct response: all potential caregivers in the home Explanation: When a neonate is discharged from the hospital, the nurse should provide discharge instructions to all potential caregivers because it is likely that all family members will play some part in caring for the neonate. Limiting the education to guardians, adult members of the family, or the primary caregiver would not prepare the rest of the family members for their role in caring for the neonate.

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position?

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

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?

Correct response: esophageal stricture Explanation: Dilatation at the anastomosis site is needed during the first years of childhood in about 50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with dehydration is not likely to develop with this surgery. Speech problems can occur if other abnormalities are present to produce them; the larynx and structures of speech are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor weight gain may be noted, but gastric ulcers should not develop from surgery to repair TEF.

The nurse is caring for a primiparous client and their neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4082 g (4.1 kg). Assessing for signs and symptoms of which condition should be a priority in this neonate?

Correct response: hypoglycemia Explanation: Postmature neonates commonly have difficulty maintaining adequate glucose reserves and usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications result primarily from a combination of advanced gestational age, placental insufficiency, and continued exposure to amniotic fluid. Delayed meconium is not associated with postterm gestation. Hyperbilirubinemia occurs in term neonates as well as postterm neonates, but unless there is an Rh incompatibility, it does not develop until after the first 24 hours of life.

Which nursing intervention is most important when working with neonates who are suspected of having congenital hypothyroidism?

Correct response: identifying the disorder early Explanation: The most important nursing intervention is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 4,650 g (4.65 kg) and is at 41 weeks' gestation. What would be the priority problem for this neonate?

Correct response: impaired gas exchange Explanation: The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing an adequate respiration rate is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, risk for impaired parent-child attachment may be appropriate once the airway is established.

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected?

Correct response: large size Explanation: Women with diabetes mellitus generally have neonates who are large but physically immature. Other common findings in these infants are hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, renal thrombosis, and congestive anomalies. The neonates do not exhibit hypertonia, hyperactivity, or scaly skin.

After completing discharge instructions for a primiparous client who is bottle-feeding their term neonate, the nurse determines that the parent understands the instructions when the parent says they should contact the health care provider (HCP) if the neonate exhibits which sign or symptom?

Correct response: passage of a liquid stool with a watery ring Explanation: The parent demonstrates an understanding of the discharge instructions when they say that they should contact the HCP if the baby has a liquid stool with a watery ring because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal; however, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.

The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which statements direct the nurse's action?

Correct response: preventing infection Explanation: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Conserving energy is not a concern for neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

Correct response: pyloric stenosis. Explanation: Projectile vomiting is a classic symptom of pyloric stenosis, which typically occurs within the first weeks of life. Upper GI X-rays confirm this diagnosis. Gastroschisis, diaphragmatic hernia, and imperforate anus would have been evident in the hours immediately after birth, and the reported symptoms don't characterize these conditions.

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

Correct response: temperature instability Explanation: Neonatal sepsis is oftentimes difficult to diagnose because many of the symptoms are nonspecific in the beginning. Sometimes the nurse uses intuition and experience and describes the baby as "not looking right." One of the first signs of sepsis is that the infant cannot maintain temperature and becomes hypothermic. Other symptoms include pallor, poor feeding, irritability, apnea and bradycardia, respiratory distress, and abdominal distention. Hypotension may be seen in neonatal sepsis, but it is a late sign, not an early sign. In infants and children, the blood pressure is the last vital sign to exhibit a change. If hypotension has occurred, the infant is already very ill. Gastric retention and blood in the stool are signs of necrotizing enterocolitis and should be monitored closely in infants who are at risk.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

Correct response: the neonate latches onto the areola and swallows audibly. Explanation: Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.

After instructing a parent about normal reflexes of term neonates, the nurse determines that the parent understands the instructions when they describe the tonic neck reflex as occurring when the neonate displays which behavior?

Correct response: turns head to the left, extends the left extremities, and flexes the right extremities Explanation: The tonic neck reflex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and flexes the right extremities. This reflex disappears in a matter of months as the neonatal nervous system matures. The stepping reflex is demonstrated when the infant is held upright near a hard, firm surface. The prone crawl reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski reflex.

Which finding is considered normal in the neonate during the first few days after birth?

Correct response: weight loss then return to birth weight Explanation: Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

The nurse is caring for a postterm newborn. What interventions will the nurse include in the client's plan of care? Select all that apply. Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Examine the indirect Coombs test.

Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Explanation: Postterm newborns are at risk for hypoglycemia, meconium aspiration, and hypothermia, so the nurse should assess for all these disorders. Respiratory distress can occur after meconium aspiration, so the infant should be monitored closely for increased respiratory rates, grunting, retractions, and nasal flaring. Encouraging early feedings helps prevent hypoglycemia. Double-wrapping infants in blankets after they have been removed from the radiant warmer is done to prevent hypothermia. An indirect Coombs test would be related to jaundice.

A nurse is caring for a newborn undergoing phototherapy for treatment of hyperbilirubinemia. Which are appropriate nursing interventions? Select all that apply. Wrap the newborn securely in two blankets under the lights. Ensure that the newborn wears a hat while in phototherapy. Monitor the newborn's temperature frequently. Assess for intake and output of the newborn. Place bilateral eye patches over the newborn's eyes while the newborn is in phototherapy.

Monitor the newborn's temperature frequently. Assess for intake and output of the newborn. Place bilateral eye patches over the newborn's eyes while the newborn is in phototherapy. Explanation: Phototherapy treats hyperbilirubinemia through the exposure of bili lights to the bare skin of the newborn. The light helps with the breakdown of the bilirubin in body so that it can be excreted through urine or stool. Because the newborn only has on a diaper and the bilateral eye patches under the bili lights, the temperature of the newborn can be very cold or very hot and must be monitored closely.

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. The neonate grasps the nurse's finger when she puts it in the palm of the neonate's hand. The neonate does stepping movements when held upright with sole of foot touching a surface. The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate turns toward the nurse's finger when she touches the neonate's cheek. The neonate displays weak, ineffective sucking.

The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking. Explanation: Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not flare when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the flaring of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek.