Abnormalities & Normal Values (Exam 2)
Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following?
40 mg/100 mL whole blood
While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment?
A weak sucking reflex
All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia?
An infant who had difficulty establishing respirations at birth
A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client?
Application of eye dressings to the infant
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply a cooling blanket
The parents of a child with phenylketonuria ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU?
Autosomal recessive
A nurse is caring for a newborn & auscultates an apical HR of 130/min. Which of the following actions should the nurse take?
Document this as an expected finding
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
Ensure the newborn's eyes are closed beneath the shield
If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia?
Feed the infant
Which of the following is a consequence of hypothermia in a newborn?
Holds breath 25 seconds
In an infant who has hypothermia, what would be an appropriate nursing diagnosis?
Impaired tissue perfusion
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
Initiate early feeding
Which of the following would you expect to assess in an infant with hypoglycemia?
Limpness/jitteriness
Which of the following data is indicative of hypothermia of the preterm infant?
Nasal flaring
A nurse is caring for a newborn who is 6 hr old & has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
Reassess the blood glucose level prior to the next feeding
The nurse tests the newborn's Babinski reflex by doing which of the following?
Stroking the lateral aspect of the sole from the heel upwards & across the ball of the foot
Which of the following describes the Babinski reflex?
The newborn's toes will hyperextend & fan apart from dorsiflexion of the big toe when one side of the foot is stroke upward from the ball of the heel & across the ball of the foot
A nurse is teaching assistive personnel how to measure a newborn's RR. Which of the following statements indicates an understanding of why the RR should be counted for a complete minute?
"The rate & rhythm of breath are irregular in newborns."
What foods should be fed & restricted for a child with PKU?
-specialized synthetic formula which PKU is removed/reduced -restrict meat, dairy products, diet drinks (artificial sweetners), & protein during pregnancy -aspartame must be avoided
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
Avoid using lotion/ointment on the newborn's skin
The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action?
Make a loud, abrupt noise to startle the newborn
A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. The finding indicates the newborn is experiencing a complication related to which of the following?
Maternal/newborn blood group incompatibility
A nurse is caring for a newborn & observes signs of diaphoresis, jitteriness, & lethargy. Which of the following actions should the nurse take?
Obtain blood glucose by heel stick
A nurse explain which reflex will promote newborn latching?
rooting
