CH 23 nursing care for newborns with special needs

22. 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

Answer A,C,E Rationale: The nurse would focus the plan of care on developmental care, which includes clustering care to promote rest and conserve energy, using flexed positioning to simulate in utero positioning, using kangaroo care to promote skin to skin sensations, swaddling with a blanket to maintain the flexed position, and providing nonnutritive sucking. p.842

7. 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

Answer: A 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 p. 836

17. After a rapid assessment determines 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

Answer: A Rationale: If resuscitation is needed, the nurse must first stabilize the newborn by drying the newborn thoroughly with a warm towel and provide warmth by placing him or her under a radiant heater to prevent rapid heat loss. Next the newborn's head is placed in a neutral position to open the airway, and the airway is cleared with a bulb syringe or suction catheter. Breathing is stimulated. Often handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. Next ventilations and then chest compressions are done. Administration of epinephrine and/or volume expanders is the last step p.833

26. 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

Answer: A Rationale: Oxygen administration is a common therapy in the neonatal intensive care unit, though the normal oxygen concentration for a preterm infant remains unknown. p 833

6. A nurse is providing care to a large for gestational age newborn. The newborn's blood glucose level was 32 mg/dL one hour ago. Breast-feeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do next? A. Administer intravenous glucose. B. Feed the newborn 2 ounces of formula. C. Initiate blow-by oxygen therapy. D. Place the newborn under a radiant warmer

Answer: A Rationale: Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. If hypoglycemia persists, then intravenous dextrose may be needed. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. p. 828

25. 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. Encourage frequent feedings B. Feed the newborn 2 ounces of dextrose water. C. Initiate blow-by oxygen therapy. D. Place the newborn under a radiant warmer.

Answer: A Rationale: Symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. Glucose water is not indicated. Blowby oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress p. 828

8. 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

Answer: A 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. p. 823

28. 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

Answer: A, B, C, D 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. p828

18. 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

Answer: A, B, E Rationale: Typically, a preterm newborn that is having problems with thermal regulation is cool to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. Blood glucose levels are probably low, leading to hypoglycemia, due to the energy expended to keep warm. p.838

16. 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

Answer: A, C Rationale: Preterm newborns are at risk for perinatal asphyxia due to surfactant deficiency, unstable chest wall, immaturity of the respiratory control centers, small respiratory passages, and inability to clear mucus from the airways. Placental deprivation places the postterm newborn at risk for perinatal asphyxia. Decreased amounts of brown fat and depleted glycogen stores place the SGA newborn at risk for problems with thermoregulation. p.830

15. 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

Answer: A, C, E Rationale: Typical characteristics of SGA newborns include a head that is disproportionately large compared to the rest of the body, wasted appearance of the extremities, reduced subcutaneous fat stores, decreased amount of breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone over buttocks and cheeks, loose and dry skin appearing oversized, and a thin umbilical cord. p. 823

9. 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. postterm.

Answer: B 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 postterm 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. p829

27. 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 giving birth to your baby at 36 weeks?" D. "Your baby is premature and needs monitoring in the NICU."

Answer: B Rationale: A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the birth demonstrates caring but does not address the woman's lack of understanding about her newborn. p 845

14. 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 determines that the teaching was successful when the class identifies which variation if a 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

Answer: B Rationale: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz (1,587 g). A very-low-birth-weight newborn would weigh less than 3 lb 5 oz (1,587 g) but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000 g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term p.822

11. 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

Answer: B 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. p. 828

20. The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which assessment finding would the nurse correlate with this situation? A. increased respirations B. flaying hands C. eupnea D. increased heart rate

Answer: B Rationale: Overstimulation may have negative effects by reducing oxygenation and causing stress. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. When overstimulated, such as by noise, lights, excessive handling, alarms, and procedures, and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may occur. p. 840

30. 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)."

Answer: B Rationale: The parents of a preterm newborn need teaching about when to notify their pediatrican 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. p 835

5. 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

Answer: B 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. p.828

10. 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.

Answer: B 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. p. 847

A nurse is assessing a postterm 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

Answer: C Rationale: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet. pg846

13. 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

Answer: C Rationale: Appropriate for gestational age (AGA) describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. Infants who are AGA have lower morbidity and mortality than other groups. The other categories all have an increased risk of complications. p.822

21. 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.

Answer: C Rationale: Assessment of pain in the newborn remains a contentious and vexing problem. According to an international consortium, principles of newborn pain prevention and management include the following: newborn pain frequently goes unrecognized and undertreated; newborns experience pain, and analgesics should be given; a procedure considered painful for an adults should also be considered painful for a newborn; newborns may be more sensitive to pain than adults; and pain behavior is frequently mistaken for irritability and agitation p.841

19. 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

Answer: C Rationale: Bulging fontanels in a preterm newborn suggest overhydration. Sunken fontanels, decreased urine output, and elevated temperature would suggest dehydration. p.838

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

Answer: C Rationale: For the preterm infant experiencing respiratory distress, the nurse would expect to handle the newborn as little as possible to reduce oxygen requirements. Other appropriate interventions include keeping the infant warm preferably in a warmed isolette to conserve the baby's energy and prevent cold stress; administer oxygen using an oxygen hood; and provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia p 837

24. 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

Answer: C Rationale: A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction. p. 830

3. 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

Answer: C 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 p 844

4. 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.

Answer: D 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 admnistering epinephrine and/or volume expansion if needed. p. 833

23. 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."

Answer: D Rationale: Instead of telling the parents to forget about what has happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation p. 844

12. 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

Answer: D Rationale: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone. p.841

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. pg838