CH 24 -- Newborn at risk: Acquired and Congenital Newborn Conditions

After assessing the status of a newborn, the nurse is concerned that this newborn has persistent pulmonary hypertension. When explaining it to the parents, the nurse would integrate knowledge about which event as having most likely occurred? Alkalosis has occurred. Foramen ovale has not closed. There is a left-to-right shunting occurring in the heart. There is a mitral insufficiency murmur.

Foramen ovale has not closed. Explanation: With persistent pulmonary hypertension, pulmonary vascular resistance is elevated to where the venous blood is diverted to some degree through fetal structures, preventing the foramen ovale or ductus arteriosus from closing as they should. This leads to a right-to-left shunting of blood into the systemic circulation. Hypoxia will result in acidosis, and there may also be a tricuspid insufficiency murmur noted on auscultation.

Which intervention is helpful for the neonate experiencing drug withdrawal? Withhold all medication to help the liver metabolize drugs. Place the isolette in a quiet area of the nursery. Place the isolette near the nurses' station for frequent contact with health care workers. Dress the neonate in loose clothing so the infant will not feel restricted.

Place the isolette in a quiet area of the nursery. Explanation: Neonates experiencing drug withdrawal commonly have sleep disturbance. The neonate should be moved to a quiet area of the nursery to minimize environmental stimuli. Medications such as phenobarbital and paregoric should be given as needed. The neonate should be swaddled to prevent him from flailing and stimulating himself.

The parents of an infant with congenital club foot question the nurse about what the treatment will be to address this problem. What initial treatment plan would the nurse explain to the parents? immediate surgery to straighten the ankle serial casting initiation of physical therapy application of bilateral braces

serial casting Explanation: Treatment for congenital club foot starts with serial casting, which is needed because of the rapid growth of the newborn. Surgery, braces, and physical therapy all have their place in the treatment of one or the other type of club foot, but they follow the initial treatment of serial casting.

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority? Review the labor and birth records. Assess the Apgar score again in 5 minutes. Complete the Ballard score. Begin resuscitation measures.

.Begin resuscitation measures. Explanation: Determine the Apgar score at 1 and 5 minutes; if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7. The Ballard score would not be performed at this time. Reviewing the L & D records or repeating the Apgar are not priorities.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred? The infant's mother probably had diabetes. The infant may have been exposed to alcohol during pregnancy. The infant may have experienced birth trauma. The infant's mother must have had a long labor.

The infant's mother probably had diabetes. Explanation: The nurse should know that the infant's mother more than likely had/has diabetes. The large size of the infant born to a mother with diabetes is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of mothers with diabetes include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who use alcohol during pregnancy, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol spectrum disorder or alcohol exposure during pregnancy do not usually have hypoglycemia problems.

A nurse is conducting a review program for a group of neonatal nurses about pulmonary complications associated with preterm birth, explaining that the most common severe adverse pulmonary outcome of preterm birth is bronchopulmonary dysplasia. Which information would the nurse address as a preventive measure? administrating tocolytics to the mother before birth start resuscitation with 100% oxygen immediately after birth immediate intubation after birth antepartum administration of steroids to the mother

antepartum administration of steroids to the mother Explanation: Bronchopulmonary dysplasia can be prevented by administering steroids to the mother in the antepartal period and exogenous surfactant to the newborn to help reduce the risk for RDS and its severity. Additional therapies include lower target oxygen saturation levels and using air instead of oxygen.

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client? application of eye dressings to the infant gentle shaking of the baby delay of feeding until bilirubin levels are normal placing light 6 inches above the newborn's bassinet

application of eye dressings to the infant Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding by either breast milk or formula, therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? legs face trunk arms

face Explanation: Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? hypoxia hemolytic disease heroin withdrawal hypoglycemia

hemolytic disease Explanation: Any infant admitted to the newborn nursery should be examined for jaundice during the first 36 hours or more. Early development of jaundice (within the first 24 hours) is a probable indication of hemolytic disease. Heroin withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. The hypoglycemic newborn's blood glucose would be low, and a newborn with hypoxia would show signs of respiratory distress.

A preterm newborn born at 30 weeks' gestation is in the NICU receiving supplemental oxygen. Based on the nurse's understanding of risk reduction for the severity of retinopathy of prematurity (ROP), the nurse monitors the oxygen saturation level, ensuring that the level is within which target range? lower mid-90s to upper mid-90s mid-80s to mid-90s upper mid-80s to mid-90s mid-80s to lower mid-90s

mid-80s to lower mid-90s Explanation: Many NICUs have adopted lower oxygen saturations ranges for preterm infants. Oxygen saturation target ranges in the mid-80s to lower mid-90s are usually safe and can reduce the severity of ROP in newborns born at less than 32 weeks' gestation.

The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: sleeps for long periods of time. weighed above average when born. has facial deformities. cries when touched.

cries when touched. Explanation: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born.

The nurse is conducting a class for a group of pregnant women who are enrolled in a methadone maintenance program. The nurse is teaching the women about the effects of heroin use disorder during pregnancy. The nurse determines that additional teaching is needed when a group member makes which statement? "Methadone does not have as many bad effects on my baby as heroin does." "My baby would probably go through withdrawal after he or she is born." "I will be able to breastfeed my baby after he or she is born." "I will have to go cold turkey from the methadone since I am pregnant."

"I will have to go cold turkey from the methadone since I am pregnant." Explanation: Methadone maintenance programs are the standard of care for women with opioid addiction. The woman needs to know that she will need to return consistently to receive the prescribed methadone dose. Methadone is not stopped during pregnancy. With methadone, there is improvement in many of the detrimental fetal effects associated with heroin use. However, withdrawal symptoms are common. The woman can breastfeed her newborn while receiving methadone.

An older infant is scheduled to have a cleft palate repair. The mother asks if she will still be able to breastfeed the baby during the postoperative phase. What is the best response by the nurse? "Yes, you will be able to breastfeed but will have to interrupt the feedings frequently." "You will not be able to breastfeed immediately after, but you can pump and feed the child with a cup." "No, you will have to put the baby on regular formula." "Yes, the surgery will not interfere with breastfeeding your child."

"You will not be able to breastfeed immediately after, but you can pump and feed the child with a cup." Explanation: For an infant who has had a palate repair, no nipples, spoons, or straws are permitted; only a drinking glass or a cup is recommended. A favorite cup from home may be reassuring to the older infant.

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant? The infant's penis will not require surgery but may never be completely straight. The circumcision may have to be revised when he is older. His ability to void and have an erection in adulthood may be impaired and surgery is needed. The parents will be taught maneuvers to perform on the penis to help straighten it out prior to repairing the urethral opening.

His ability to void and have an erection in adulthood may be impaired and surgery is needed. Explanation: Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadias are never circumcised because the foreskin may be needed for later repairs.

The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately? Bright red blood from the mouth Bradycardia Severe cyanosis Vomiting

Severe cyanosis Explanation: Esophageal atresia is the absence of a normal esophageal passage from the pharynx to the stomach, which results in fluids and mucus spilling into the lungs. This can lead to respiratory distress manifested by excessive drooling and periods of respiratory distress with choking and cyanosis. No feeding should be given until the newborn has been examined. If feeding is attempted, the newborn chokes, coughs, and regurgitates; becomes deeply cyanotic; and appears to be in severe respiratory distress. Bright red blood from the mouth is not an indication of esophageal atresia. Bradycardia and vomiting are not signs of respiratory distress.

A client at 6 weeks' gestation asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? Pork, beans, and poultry Milk, yogurt, and cheese Spinach, oranges, and beans Bananas, avocados, and coconut

Spinach, oranges, and beans Explanation: Folic acid assists in preventing the incidence of neural tube disorders. These foods include green, leafy vegetables; citrus fruits, beans, and fortified breads; cereals, rice, and pasta. Milk, yogurt, and cheese are high in calcium. Bananas, avocados, and coconut are high in potassium. Pork, beans, and poultry are high in iron.

A nurse is caring for a newborn with necrotizing enterocolitis (NEC) who is scheduled to undergo surgery for a bowel resection. The infant's parents wish to know the implications of the surgery. What information should the nurse provide to the parents regarding this surgery? Surgery requires placement of a proximal enterostomy. Surgery will prevent long-term medical problems. Surgery prevents the infant from needing enteral feedings after the repair. Surgically treated NEC is a short process.

Surgery requires placement of a proximal enterostomy. Explanation: The nurse should inform the parents that surgery for NEC requires the placement of a proximal enterostomy and ostomy care. Surgically treated NEC is a lengthy process, and the amount of bowel that has necrosed, as determined during the bowel resection, significantly increases the likelihood that infants requiring surgery for NEC may have long-term medical problems. If surgery for NEC is required, enteral feedings may be required for a protracted period of time.

The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? The large-for-gestational-age neonate The neonate delivered by cesarean section The neonate whose mother received limited prenatal care The neonate born at 41 weeks' gestation

The neonate delivered by cesarean section Explanation: While every neonate has the respiratory system assessed, some are at higher risk of complications than others. The neonate born via cesarean section is at highest risk for TTN since this infant did not have the opportunity of having fluid expressed from the lungs as he/she descended down the birth canal. The other options are not in the high-risk category.

The nurse is completing gavage feedings for the preterm neonate every 2 hours. Which rationale is most correct? The neonate gulps if fed orally, which creates indigestion. The neonate can only absorb minimal feedings. The neonate needs to gain weight and muscle strength. The neonate requires food in the gut to avoid atrophy of the mucosa.

The neonate requires food in the gut to avoid atrophy of the mucosa. Explanation: Frequent, small amounts of feeding are necessary to keep the gastrointestinal system functioning normally. Lack of food in the gut leads to atrophy of the mucosa. At that point it becomes more difficult to initiate feedings. Absorption of the nutrients and gaining weight and strength are not the rationale but a secondary benefit for the feedings. It is true that neonates have difficulty coordinating breathing and sucking oral fluids but it is not the most correct rationale for gavage feedings.

Which measure would the nurse expect to be included in the plan of care for an infant of a mother with diabetes who has a serum calcium level of 6.2 mg/dl (1.55 mmol/l)? administration of calcium gluconate initiation of phototherapy initiation of oral feedings infusions of intravenous glucose

administration of calcium gluconate Explanation: Serum calcium levels less than 7 mg/dl (1.75 mmol/l) indicate the need for supplementation with oral or IV calcium gluconate. Phototherapy would be used if the infant develops hyperbilirubinemia. Intravenous glucose solutions would be used to stabilize the infant's blood glucose levels and prevent hypoglycemia. Feedings help to control glucose levels, reduce hematocrit, and promote bilirubin excretion.

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems? angiography arterial blood gases chest x-rays echocardiogram

arterial blood gases Explanation: Arterial blood gases are obtained to determine the oxygenation levels and to help differentiate lung disease from heart disease. Chest x-rays will help identify cardiac size, shape, and position. An echocardiogram will evaluate the heart anatomy and flow defects. An angiography will be conducted to prepare the client for cardiac surgery, if needed.

The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily? nasogastric tube intravenous fluids colostomy nasal cannula for oxygen

colostomy Explanation: Surgical intervention is needed for both high and low types of imperforated anus. Surgery for a high type of defect involves a colostomy in the newborn period, with corrective surgery performed in stages to allow for growth. The newborn will require intravenous fluids, nasogastric tube attached to low suction, and oxygen in the immediate postoperative period. Once bowel function has become established, these should no longer be needed.

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? ankyloglossia esophageal atresia torticollis clubfoot (congenital talipes equinovarus)

esophageal atresia Explanation: Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

A nurse is caring for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused the nurse to suspect this might be present? a difficult second stage of labor hydramnios bleeding at 32 weeks' gestation oligohydramnios

hydramnios Explanation: Because a fetus swallows amniotic fluid, when there is an obstruction of the esophagus, amniotic fluid accumulates, leading to hydramnios.

A nurse caring for a client in premature labor knows that the best indicator of fetal lung maturity is which data? meconium in the amniotic fluid Absence of phosphatidylglycerol in amniotic fluid lecithin to sphingomyelin ratio of more than 2:1 glucocorticoid treatment just before delivery

lecithin to sphingomyelin ratio of more than 2:1 Explanation: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks, and sphingomyelin concentrations remain stable. Meconium is released due to fetal stress before delivery, but it's chronic fetal stress that matures lungs. Glucocorticoids must be given at least 48 hours before delivery. The presence of phosphatidylglycerol indicates lung maturity.

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document? loud, harsh murmur delayed growth and development fatigue and dyspnea bounding pulse

loud, harsh murmur Explanation: Children with ventricular septal defects have a characteristic loud, harsh murmur. Fatigue and dyspnea, delayed growth and development, and a bounding pulse are seen in the child with patent ductus arteriosus.

Assessment reveals that a young client has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test should the nurse expect to be used to monitor the fetus for this birth defect? folic acid levels maternal serum alpha-fetoprotein levels

maternal serum alpha-fetoprotein levels Explanation: In pregnancies in which the fetus has a neural tube defect, the level of maternal serum alpha-fetoprotein in the amniotic fluid and pregnant client's serum is elevated. By monitoring this level throughout the pregnancy, it is possible to be aware of this defect before the birth. Genetic studies, folic acid levels, and cultures for infections are not utilized to detect neural tube defects.

A neonatal intensive care nurse is caring for a preterm newborn diagnosed with transient tachypnea who is NPO and receiving intravenous fluid therapy. When would the nurse expect the newborn to begin oral feedings? when intake and output correlate when the oxygen saturation level is at 92% when serum glucose is 30 mg/dl (1.7 mmol) when the respiratory rate is 44 BPM

when the respiratory rate is 44 BPM Explanation: Nursing management of transient tachypnea of the newborn (TTN) is supportive with the administration of intravenous (IV) fluids and/or gavage feedings until the respiratory rate decreases enough to allow safe oral feeding. RR of 44 bpm is normal. The O2 sat level is too low to start oral feedings. The glucose levels indicate hypoglycemia. Intake and output measurements do not indicate the newborn will manage oral feedings.

When caring preoperatively for a neonate with a diagnosed tracheoesophageal fistula, which symptoms are anticipated? Select all that apply. Cyanosis Excessive drooling Bradypnea Heartburn with feedings Elevated heart rate Frothing

Excessive drooling Cyanosis Elevated heart rate Frothing Explanation: Symptoms resulting from a diagnosed tracheoesophageal fistula include frothing, excessive drooling, cyanosis from mucus production, an elevated heart rate from anxiety of coughing, and difficulty breathing. Once the tracheoesophageal fistula is diagnosed, no oral feedings will be given. This neonate does not have bradypnea.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration? Place a wedge under the child's crib. Place the child on the abdomen. Place the child on the back. Position the child on the side.

Position the child on the side. Explanation: To facilitate drainage of mucus and secretions, the nurse should position the infant on the side, never on the abdomen, after a cleft lip repair

The nurse is working with a group of parents of newborns who have congenital heart disorders. Which statement made by the parents requires further assessment by the nurse? "My newborn's chest measurement is the same as their head." "When I move my newborn's legs up toward their chest I hear a click." "They say my newborn has a heart murmur but it may go away." "My newborn gets so tired when eating."

"My newborn gets so tired when eating." Explanation: Newborns with cardiac anomalies that may be developing congestive heart failure have a history of being poor eaters, tiring easily from the effort to suck, and failing to grow or thrive normally. A murmur is not a sign of congestive heart failure. At times during infancy, the chest and head would measure the same without this being a concern. With a congenital dislocation of the hip, an audible click may be heard.

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? "We'll take off the patches on his eyes when we're feeding him so he can look at us." "We should see reddened areas on his skin, which means the treatment is working." "We will turn him every ½ hour to make sure that his whole body is exposed." "We'll place the lights so that they are about 5 inches above our baby at all times."

"We'll take off the patches on his eyes when we're feeding him so he can look at us." Explanation: The lights are to be positioned about 12 to 30 inches above the newborn. The newborn is turned every 2 hours while under the bilirubin lights. Eye patches are removed during feedings so that the newborn can interact with the caregiver. Evidence of effectiveness is indicated by loose, green stools indicating that the bilirubin is being broken down.

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur? transposition of the great vessels patent ductus arteriosus ventricular septal defect coarctation of the aorta

ventricular septal defect Explanation: A ventricular septal defect is the most common intracardiac defect. It consists of an abnormal opening in the septum between the two ventricles.

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply. Cover the newborn's eyes. Assess the newborn's skin. Maintain protective cover around infant. Increase fluid intake. Remove the infant to feed and change.

Assess the newborn's skin. Increase fluid intake. Maintain protective cover around infant. Remove the infant to feed and change. Explanation: Nursing interventions are different when utilizing phototherapy lights and a fiberoptic blanket. The main difference is that the fiberoptic blanket does not require the newborn to maintain eye shields. All the other options are correct.

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? Aspirin Morphine Acetaminophen Ibuprofen

Morphine Explanation: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid, is given to the client to ease the withdrawal symptoms and also gradually remove opioids from the system. The other options do not ease withdrawal symptoms.

A nurse is caring for a newborn with asphyxia. Which nursing management is involved when treating a newborn with asphyxia? Administer IV fluids. Ensure effective resuscitation measures. Administer surfactant as prescribed. Ensure adequate tissue perfusion.

Ensure effective resuscitation measures. Explanation: Ensuring effective resuscitation measures is the nursing intervention involved when treating a newborn for asphyxia. Ensuring adequate tissue perfusion and administering surfactant are nursing interventions involved in the care of newborns with meconium aspiration syndrome. Similarly, administering IV fluids is a nursing intervention involved in the care of newborns with transient tachypnea.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis? high-pitched cry poor suck reflex meconium stools bloody stools

bloody stools Explanation: NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria.

In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of: genitourinary tract. lymphatic system. cerebrospinal fluid. circulatory blood flow.

cerebrospinal fluid. Explanation: In congenital hydrocephalus, an obstruction occurs and cerebrospinal fluid is not able to pass between the ventricles and the spinal cord.

When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need? prevention of pneumonia nutrition prevention of oral infection visual stimulation

nutrition Explanation: An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is a major concern.

It would be best to place an infant with a meningomyelocele in which position prior to surgery? semi-Fowler in an infant chair on the stomach (prone) on the left side with the head dependent supine with the head elevated

on the stomach (prone) Explanation: Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion.

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? maculopapular rash greenish stool bronze-colored skin absent Moro reflex

Absent Moro reflex Explanation: An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronze colored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention.

A nurse is caring for a neonate with transient tachypnea of the newborn. Which is the priority nursing intervention? Perform gentle suctioning. Maintain adequate hydration. Administer IV fluids; gavage feedings. Monitor for signs of hypotonia.

Administer IV fluids; gavage feedings. Explanation: The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intraventricular hemorrhage.

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required? "After this surgery is done tomorrow, my baby will be able to eat and drink." "Intravenous fluids are going to be needed so that the baby won't get dehydrated." "They will be placing a tube in the stomach during surgery." "The baby will have tubes in the chest to drain chest fluids."

"After this surgery is done tomorrow, my baby will be able to eat and drink." Explanation: The newborn will need IV fluids to maintain optimal hydration. The first stage of surgery may involve a gastrostomy and a method of draining the proximal esophageal pouch. A chest tube is inserted to drain chest fluids. If the repair is complex, surgery may need to be done in stages.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? serum glucose level of 60 mg/dl hyperalert state jitteriness excessive crying

Jitterness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Excessive crying isn't found in hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? Ineffective thermoregulation related to decreased amount of subcutaneous fat Imbalanced nutrition: Less than body requirements related to the premature digestive system Grieving related to the loss of "a healthy full-term newborn" Risk for injury related to the very thin epidermis layer of skin

Ineffective thermoregulation related to decreased amount of subcutaneous fat Explanation: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority.

A nursing instructor is leading a group discussion on congenital hydrocephalus. The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type? Defective absorption of cerebrospinal fluid Opening between the ventricles and the spinal cord that usually closes at birth Obstruction that keeps CSF from passing between the ventricles and the spinal cord Decreased production of cerebrospinal fluid

Obstruction that keeps CSF from passing between the ventricles and the spinal cord Explanation: In the noncommunicating type of congenital hydrocephalus, an obstruction occurs, and CSF is not able to pass between the ventricles and the spinal cord. The blockage causes increased pressure on the brain or spinal cord. In the communicating type of hydrocephalus, no obstruction of the free flow of CSF exists between the ventricles and the spinal theca; rather, the condition is caused by defective absorption of CSF. There is no concern of decreased production of CSF and no opening between the ventricles and spinal cord in hydrocephalus.

Which nursing action is required when caring for the post-term infant? IV initiation Echocardiogram at the end of pregnancy Serial blood glucose levels temperature checks every 2 hours

Serial blood glucose levels Explanation: Of the options provided, the one that is required is serial blood glucose levels. The newborn may require IV glucose infusion to stabilize glucose level. The rest of the options are on an as-needed basis.

Which nursing actions limit overstimulation of the preterm infant? Select all that apply. Coordinate nursing care. Tap on the isolette before opening the door. Keep lights low in the nursery. Speak softly to the infant. Frequently open the isolette portholes.

Speak softly to the infant. Keep lights low in the nursery. Coordinate nursing care. Explanation: It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions. Tapping and opening the isolette portholes can startle the infant.

The nurse is caring for a newborn who is large-for-gestational-age (LGA). Which characteristics are documented as a contributing factor? Select all that apply. The neonate is a female. Both parents are of a larger stature and size. The father is obese but mother is of normal weight. The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes.

The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size. Explanation: Common contributing factors for a large-for-gestational-age neonate are the mother having a history of previous LGA neonates; the mother having a high glucose level due to a poorly controlled diabetic status; and genetic characteristics of the parents being of a larger size and stature. A larger-sized infant is more correlated with an obese mother than obese father. Males are more likely to be LGA.

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification? The skin is jaundiced. Milia is noted on the nose. The neonate ate 1 to 2 oz of formula. The neonate slept for 18 hours.

The skin is jaundiced. Explanation: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. This neonate exhibits pathologic jaundice, which needs to be reported immediately. Milia is common on the newborn. It is appropriate for the newborn to sleep for most of the day and eat a couple ounces of formula.

A nurse is caring for a 25-year-old G1P0 at 37 weeks' gestation. The client's history indicates that the client has had alcohol abuse disorder throughout their pregnancy. What signs and symptoms does the nurse expect the newborn to exhibit? SATA Thin upper lip flat midface large, narrow spaced eyes increased appetite jitteriness high-pitched shrill cry easily consoled

Thin upper lip jitteriness high-pitched shrill cry Flat midface Explanation: Newborns born with FAS have characteristic facial features, are more susceptible to congenital defects, and often have developmental delays. Newborns with FAS have a high-pitched and shrill cry and are generally jittery. Newborns with FAS have a flat midface and a thin upper lip. Newborns with FAS have small and wide-spaced eyes not large narrow-spaced eyes.

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have: a protruding sac that contains abdominal contents. an extremely large and rapidly growing head. a membrane between the rectum and the anus. a partial to complete paralysis in the lower extremities.

a partial to complete paralysis in the lower extremities. Explanation: In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. The effects of this defect vary in severity from sensory loss/partial paralysis below the lesion to complete flaccid paralysis of all muscles below the lesion.

The nurse is assessing a large-for-gestational-age newborn who had shoulder dystocia at birth. Which assessment findings would indicate a possible fracture? absent sucking, rooting, and Babinski reflexes exaggerated Moro, step, and palmar reflexes absent Moro, bicep, and radial reflexes absent Moro, radial, and grasp reflexes

absent Moro, bicep, and radial reflexes Explanation: Common types of birth trauma include a brachial plexus injury seen primarily in large babies or babies with shoulder dystocia. It results from stretching, hemorrhage within a nerve, or tearing of the nerve or the roots associated with cervical cord injury. Erb's palsy is an upper brachial plexus injury evidenced with an absent Moro, bicep, and radial reflex. The grasp reflex is usually present. Klumpke's palsy is manifested by weakness in the hand and wrist; grasp reflex is absent.

A newborn is diagnosed with a birth injury secondary to shoulder dystocia. The nurse suspects an upper brachial plexus injury based on which finding? present Moro reflex absent radial reflex absent grasp reflex present bicep reflex

absent radial reflex Explanation: With an upper brachial plexus injury, also known as Erb palsy, the involved extremity usually presents adducted, prone, and internally rotated; shoulder movement is absent; Moro, bicep, and radial reflexes are absent, but the grasp reflex is usually present. Klumpke palsy, a lower brachial plexus injury, is manifested by weakness in the hand and wrist and an absent grasp reflex.

A pregnant woman gives birth to a small-for-gestational-age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy? alcohol cocaine heroin methamphetamine

alcohol Explanation: This child's features match those of fetal alcohol spectrum disorder, including microcephaly, small palpebral (eyelid) fissures, abnormally small eyes, and fetal growth restriction.

A nurse is caring for a newborn who was diagnosed with an imperforate anus. Assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. Which action by the nurse would be appropriate? give gavage feedings suction the throat clear the airway prepare for endotracheal intubation

clear the airway Explanation: The newborn is showing signs of esophageal atresia based on the assessment. The nurse would clear the airway and notify the health care provider. Newborns with imperforate anus often have other anomalies including esophageal atresia. With this condition, a gastric tube cannot be inserted beyond a certain point because the esophagus ends in a blind pouch. Therefore gavage feedings would be inappropriate. Although the newborn has copious mucus, suctioning the throat and endotracheal intubation are not warranted. Excess secretions should be removed with a bulb syringe.

Periventricular-intraventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which diagnostic tool to confirm the diagnosis? arterial blood gases cranial ultrasound chest X-ray blood glucose level

cranial ultrasound Explanation: The diagnostic tool of choice to detect periventricular-intraventricular hemorrhage is a cranial ultrasound. Arterial blood gases would be helpful in evaluating for metabolic acidosis. Blood glucose levels provide information about the newborn's glucose stability. Chest x-ray would provide no information related to bleeding in the brain.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? high-pitched, shrill cry intermittent tachypnea expiratory grunting bile-stained emesis

expiratory grunting Explanation: Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome. A high-pitched cry may be noted in periventricular hemorrhage/intraventricular hemorrhage. Bile-stained emesis occurs in necrotizing enterocolitis. Intermittent tachypnea can be indicative of transient tachypnea of the newborn or any mild respiratory distress problem.

The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated? intellectual disability congenital heart defects increased intracranial pressure strangulated intestine

intellectual disability Explanation: Phenylketonuria (PKU) is a recessive hereditary defect of metabolism that, if untreated, causes severe intellectual disability. The nurse should provide the parents with information describing the pros and cons of the treatment. This disorder is not related to congenital heart defects, increased intracranial pressure, or to a strangulated intestine.

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication? respiratory distress syndrome intraventricular hemorrhage (IVH) cold stress retinopathy of prematurity (ROP)

intraventricular hemorrhage (IVH) Explanation: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full or bulging fontanel (fontanelle), cyanosis, and increased head circumference.

What would the nurse use as evidence of effective resuscitation? pink tongue weak cry pulse rate of 60 beats per minute retractions

pink tongue Explanation: Resuscitation is continued until the newborn has a pulse above 100 beats per minute, a good cry, or good breathing efforts and a pink tongue.

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply. frequent yawning respirations of 43 breaths per minute tremors nasal flaring coordinated sucking

tremors frequent yawning Nasal flaring Explanation: Manifestations of intrauterine drug exposure in the newborn include tremors, frequent yawning, uncoordinated sucking, respirations greater than 60 breaths per minute, and nasal flaring.

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage? Allow the sac to dry out to "toughen" it. Cover the sac with a water-soluble lubricant and a dry sterile dressing. Apply a sterile dressing moistened in a warm, sterile saline solution. Cover the sac with petroleum jelly and a dry sterile dressing.

Apply a sterile dressing moistened in a warm, sterile saline solution. Explanation: Until surgery is performed, the sac must be covered with a sterile dressing moistened in a warm, sterile solution (often saline). The nurse should change this dressing every 2 hours and not allow it to dry to avoid damage to the covering of the sac.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client? Place the infant in a cool environment to prevent overheating. Provide oxygen by oxygen hood or ventilator. Administer anticonvulsants as prescribed. Encourage the parents to hold the infant for bonding.

Provide oxygen by oxygen hood or ventilator. Explanation: The nurse should administer oxygen to the infant in whatever manner needed to help maintain the infant's oxygen levels. Anticonvulsants are not necessary in treating this disorder. The infant's physical environment should be warm, not cool, and stimulation should be limited for these clients.

The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care? Spina bifida major Spina bifida with myelomeningocele Spina bifida occulta Spina bifida with meningocele

Spina bifida with myelomeningocele Explanation: The neonate shown was born with spina bifida myelomeningocele, which is a sac containing the spinal cord and meninges with nerves roots embedded in the wall. Spina bifida occulta is a bony defect that occurs without soft tissue involvement. These neonates are asymptomatic and present no problems. A neonate with spina bifida with a meningocele would have spinal meninges protrude through a bony defect forming a sac. There is no condition as spina bifida major.

The nurse assesses an infant. Which finding may indicate heart failure? diminished peripheral pulses color of hands and feet capillary refill time blood glucose level

diminished peripheral pulses Explanation: After birth, the nurse should carefully assess the newborn's cardiovascular and respiratory systems, looking for signs and symptoms of respiratory distress, cyanosis, or congestive heart failure that might indicate a cardiac anomaly. Assess rate, rhythm, and heart sounds, reporting any abnormalities immediately. Note any signs of heart failure, including edema, diminished peripheral pulses, hepatomegaly, tachycardia, diaphoresis, respiratory distress with tachypnea, peripheral pallor, and irritability. Capillary refill time and the color of the infant's hands and feet are important to note, but do not indicate possible heart failure and neither does the blood glucose level.

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? after 5 days postpartum often with formula-fed babies during the first 24 hours of life between 2 and 4 days of life

during the first 24 hours of life Explanation: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies.

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed by which method? blood work X-ray feeling the palate with a gloved finger or using a tongue blade ultrasound

feeling the palate with a gloved finger or using a tongue blade Explanation: Diagnosis of cleft palate is made at birth with close inspection of the newborn's palate. To be certain that a cleft palate is not missed, the examiner must insert a gloved finger into the newborn's mouth to feel the palate to determine that it is intact. The other tests cannot confirm a cleft palate.

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment? above average birth weight lethargic and sleepy hyperactive and irritable large head circumference

hyperactive and irritable Explanation: The newborn that is withdrawing from alcohol typically is hyperactive, irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of fetal alcohol spectrum disorder include low birth weight, and small height and head circumference. This newborn is prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia.

A newborn is suspected of having gastroschisis at birth. How does the nurse differentiate this condition from other congenital conditions? The abdominal contents are contained within a thin, transparent sac. The exposed intestines appear reddened and swollen and have no sac around them. The newborn is vomiting and the abdomen appears distended. The umbilical cord comes out of the middle of the herniated organ.

The exposed intestines appear reddened and swollen and have no sac around them. Explanation: The nurse recognizes that gastroschisis is a herniation of abdominal contents in which there is no peritoneal sac protecting herniated organs. A peritoneal sac is present in omphalocele. In gastroschisis, the herniated organs are not normal; they are unprotected and become thickened, edematous, and inflamed because of exposure to amniotic fluid. This herniation of abdominal contents occurs to the right of the umbilical cord, not into the base of it. That is an omphalocele. If the newborn is vomiting and the abdomen appears distended, this is most likely due to intestinal atresia.

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? The newborn has caput succedaneum that will go away within the first week of life. This is a cephalohematoma that typically spontaneously resolves without interventions.

This is a cephalohematoma that typically spontaneously resolves without interventions. Explanation: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia.

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding? peripheral cyanosis see-saw respirations slightly diminished breath sounds respiratory distress occurring by 6 hours of age

see-saw respirations Explanation: Typically the newborn with RDS demonstrates signs and symptoms of severe respiratory distress at birth or within a few hours of birth. Fine, inspiratory crackles are noted on auscultation of a newborn with RDS. See-saw respirations are characteristic of RDS. A newborn with RDS typically demonstrates generalized cyanosis.

Infants born with a diaphragmatic hernia are provided supportive treatment until they can have surgery to repair the defect. What medications are usually given to these infants to improve their oxygen saturations and respiratory status? Select all that apply. surfactant bronchodilators steroids inotropics plasma expanders

steroids inotropics surfactant Explanation: Administer prescribed medications as prescribed. For example, give inotropics to support systemic blood pressure. Administer surfactant, steroids, and inhaled nitric oxide as ordered to correct hypoxia and acid-base imbalance. Most infants with diaphragmatic hernia will require ECMO (extracorporeal membrane oxygenation) support to stabilize their oxygen levels and rest the lungs.

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement? "Hydrocephalus may not be diagnosed until after a few weeks or months of life." "Congenital defects may be caused by genetic or environmental factors." "All congenital disorders can be diagnosed at birth." "Hydrocephalus may be recognized at birth."

"All congenital disorders can be diagnosed at birth." Explanation: All congenital disorders are not diagnosed at birth. Hydrocephalus is one such disorder that may be diagnosed at birth but also may not be diagnosed until after a few weeks or months. It is also true that congenital defects may be caused by both genetics and environmental factors.

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement? "It is upsetting to me that he is in pain when he urinates." "We hadn't decided about circumcision, but he will have to be circumcised before they do the surgery." "At least he won't have to have surgery until he is almost ready to start school." "Being able to most likely correct this in one stage rather than several is reassuring."

"Being able to most likely correct this in one stage rather than several is reassuring." Explanation: Surgical repair is often accomplished in one stage and is often done as outpatient surgery. Surgical repair is desirable between the ages of 6 and 18 months, before body image and castration anxiety become problems. Urination is not affected, but the boy cannot void while standing in the normal male fashion. These newborns should not be circumcised because the foreskin is used in the repair.

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response? "Disturbances to the bladder with diaper changes will be kept to a minimum." "The bladder will be covered in a sterile plastic bag to keep it moist." "Your baby will be cared for in the prone position with a cover over the bladder." "We will care for the bladder with frequent sterile tub baths to keep it moist."

"The bladder will be covered in a sterile plastic bag to keep it moist." Explanation: In the preoperative period, infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only (rather than immersing him or her in water) to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary.

A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate? "Your newborn has a collection of blood that was caused by tearing of the veins and is pushing on the brain. This collection of blood will need to be drained." "You must have had some problems during labor with keeping your blood pressure under control. Your newborn will need to be handled gently." "The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days." "The tiny blood vessels under your newborn's skull broke during labor and caused the swelling. It will get better in about 2 to 3 weeks."

"The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days." Explanation: Assessment indicates that the newborn has caput succedaneum. This is soft tissue swelling caused by edema of the head against the dilating cervix during the birth process. In caput succedaneum, swelling is not limited by suture lines; it extends across the midline and is associated with head molding. It does not usually cause complications other than a misshapen head and usually resolves over the first few days without treatment. Cephalohematoma is the subperiosteal collection of blood secondary to the rupture of blood vessels between the skull and periosteum. Suture lines delineate its extent and it is usually located on one side, over the parietal bone. Cephalohematoma resolves gradually over 2 to 3 weeks without treatment.

A nurse makes a home visit to a new mother and her 5-day-old newborn. Assessment of the newborn reveals slight yellowing of the skin on the face and forehead and slowed skin turgor. The mother tells the nurse that she's been having trouble breastfeeding the newborn. "My baby's been feeding about every 4 to 5 hours." Additional assessment reveals about 3 wet diapers per day and 1 to 2 stools per day. Which action by the nurse would be the priority? Call the provider to obtain a prescription for a bilirubin level. Arrange for home phototherapy. Evaluate the mother's technique for breastfeeding. Measure the newborn's abdominal girth.

Call the provider to obtain a prescription for a bilirubin level. Explanation: The assessment findings and report from the mother suggest late-onset breastfeeding jaundice. The nurse should report the findings to the provider and obtain a prescription for a bilirubin level. Once the results are obtained, then the decision for home phototherapy can be made. Although it would be helpful to evaluate the mother's breastfeeding technique to promote enhanced breastfeeding, the priority is to confirm hyperbilirubinemia and institute measures to lower the bilirubin level. Measuring the newborn's abdominal girth would be unnecessary.

At birth, a newborn is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the newborn's positioning of the arm is a result of the palsy and not just a preferred position. Which neonatal reflex should the nurse explain to the parent? Babinski Moro rooting Stepping

Moro Explanation: When a newborn has brachial plexus palsy, there will be asymmetry of the Moro reflex. The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. A positive Babinski sign indicates neurologic immaturity.

The nurse is caring for a neonate. Which is the most important step the nurse can take to prevent and control infection? Use sterile technique for all caregiving. Wear gloves at all times. Practice meticulous handwashing. Check frequently for signs of infection.

Practice meticulous handwashing. Explanation: To prevent and control infection, the nurse should practice meticulous handwashing, scrubbing for 3 minutes before entering the nursery, washing frequently during caregiving activities, and scrubbing for 1 minute after providing care.

A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time? Increase the flow of IV fluids and maintain NPO status. Assess and administer pain medication. Assess surgical site for signs of infection. Notify the primary care provider immediately.

Notify the primary care provider immediately. Explanation: The projectile vomiting should raise suspicions of increasing intracranial pressure and requires emergent intervention, so the nurse should notify the primary care provider immediately. Symptoms of increased intracranial pressure (ICP) may also include irritability, restlessness, personality change, high-pitched cry, ataxia, failure to thrive, seizures, severe headache, changes in level of consciousness, and papilledema. At least every 2 to 4 hours, the nurse should monitor the newborn's level of consciousness, check the pupils for equality and reaction, monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability. Edema and localized redness at the surgical site are potential indications of an infection. Assessing for pain and administering pain medication in this situation can result in the symptoms being masked and the infant could die. Increasing the fluid rate could contribute to the increased volume of fluids in the brain and would exacerbate the situation.

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out? Galactosemia Turner syndrome Phenylketonuria Congenital hypothyroidism

Phenylketonuria Explanation: There is a characteristic musty smell to the urine in the child with phenylketonuria. None of the other disorders affect the urine or the smell of the urine.

A newborn is born diagnosed with an omphalocele. What will the nurse prioritize in the care plan during the preoperative period? Place the infant in a sterile bowel bag. Place the covered infant under the radiant warmer. Swaddle the infant in sterile newborn blankets. Care for the infant in a sterile isolette.

Place the infant in a sterile bowel bag. Explanation: Nursing management of newborns with omphalocele must focus on preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss, and protecting the exposed abdominal contents. This can be accomplished by placing the infant in a sterile bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss. The infant may be cared for in an isolette, but a sterile bowel bag is the key to care. Blankets or covering the infant under a radiant warmer does not provide an appropriate environment in order to care for an omphalocele.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn? Prevent aspiration by elevating the head of the bed and inserting an NG tube to low suction. Document the amount and color of esophageal drainage. Provide NG feedings only. Administer antibiotics and total parenteral nutrition as prescribed.

Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction. Explanation: The preoperative nursing care focuses on preventing aspiration by elevating the head of the bed and inserting an NG tube to low suction to prevent aspiration. Documenting the amount and color of drainage is not needed with the NG tube in place. An infant with esophageal atresia is NPO and fed nothing until after the defect is repaired. Administering antibiotics and total parenteral nutrition is a postoperative nursing intervention when caring for a newborn with esophageal atresia.

The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child? Providing caregiver teaching Preventing infection Promoting comfort measures Reducing family anxiety

Preventing infection Explanation: The highest priority nursing goal is preventing infection because of the vulnerability of the myelomeningocele sac.

The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort? Promote parental bonding Swaddle and decrease stimulation Administer benzodiazepines Provide 1 ounce of formula

Swaddle and decrease stimulation Explanation: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.

The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority? The neonate will be free from infection. The neonate will not cry during diapering. The neonate will exhibit signs of bonding with parents. The neonate will urinate 2 to 3 ml/kg/hour

The neonate will be free from infection. Explanation: The highest priority goal is that the neonate will be free from infection. This neonate has open mucosa of the bladder. In addition, the neonate's urinary tract is developed and leads to the bladder and then the kidneys. Nursing intervention must include frequent vital signs; inspection of the site; observation for drainage, color and clarity of urine in diaper; and frequent urinalysis as ordered until surgical correction. Bonding is always a goal when caring for a neonate and family. Having an adequate urine output is an appropriate goal. Due to the sensitive nature of the mucosa, it is important for the neonate to not experience discomfort, particularly when the area is being cleansed.

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which statement is most accurately related to this blood test? The test is done after the newborn has ingested protein. If the test is not done the newborn could be intellectually disabled. The test is done by drawing blood from the infant's umbilical cord. It is common to perform this test after the newborn is 5 days old.

The test is done after the newborn has ingested protein. Explanation: As soon as the newborn with phenylketonuria begins to take milk, phenylalanine builds up in the blood serum to as much as 20 times the normal level. This build-up occurs so quickly that increased levels of phenylalanine appear in the blood after only 1 or 2 days of ingestion of milk.

Which congenital condition is an immediate emergency requiring notification of the health care provider? Atrial septal defect Hypospadias Cleft palate Tracheoesophageal fistula

Tracheoesophageal fistula Explanation: The congenital condition which is a medical emergency is a tracheoesophageal fistula. This condition can lead to respiratory distress and pneumonitis. Hypospadias is the urethra opening terminating on the ventral surface of the penis, instead of the tip. Cleft palate is the opening in the roof of the mouth. An atrial septal defect is an opening between the right and left atrial. Hypospadias, cleft palate, and an atrial septal defect may be surgically repaired but are not immediate emergencies.

The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations? Help the child to understand his or her limitations. Keep the family informed about new and effective treatments. Model good medical practices for the child's family. Use reflective listening with nonjudgmental support.

Use reflective listening with nonjudgmental support. Explanation: Families are naturally apprehensive and find it difficult not to overprotect a child who is ill. They often increase the child's anxiety and cause fear in the child about participating in normal activities. Children are rather sensible about finding their own limitations and usually limit their activities to their capacity if they are not made unduly apprehensive. Some families can adjust well and provide guidance and security for the sick child.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? pink skin with noted blue extremities soft, flat anterior fontanels (fontanelles) a sudden drop in hematocrit intake and output for 8 hours

a sudden drop in hematocrit Explanation: The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels (fontanelles), changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.

As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)? the term male newborn, born by cesarean birth, whose mother has respiratory allergies a term female newborn, born vaginally, whose mother has chronic obstructive pulmonary disease the term female newborn, born by a mid-forceps assist, whose mother has hypothyroidism a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus

a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus Explanation: It is necessary to review the maternal history for risk factors associated with RDS. Risk factors in the term infant placing the infant at most risk include a cesarean birth in the absence of preceding labor, male gender, and maternal diabetes, which produces high levels of insulin that inhibit surfactant production. The other infant situations would not be the priority.

What are the causes of retinopathy of the preterm newborn? Select all that apply. fragility of blood vessels in the eyes in response to changes on oxygenation. insufficient oxygenation in an Isolette shock alkalosis assistive ventilation with high oxygen content

assistive ventilation with high oxygen content fragility of blood vessels in the eyes in response to changes on oxygenation. shock Explanation: Retinopathy of the preterm newborn typically develops in both the eyes secondary to an injury such as hyperoxemia resulting from prolonged assistive ventilation and high oxygen exposure, fragility of retinal blood vessels in response to changes in oxygenation, and shock. Alkalosis does not contribute to this problem; acidosis does.

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done: between the age of 12 to 18 weeks. between the age of 6 to 12 weeks. between the age of 8 to 14 weeks. between the age of 10 to 16 weeks.

between the age of 6 to 12 weeks. Explanation: Treatment of cleft lip is surgical repair between the ages of 6 to 12 weeks. It is important to repair this anomaly as soon as possible to facilitate bonding between the newborn and the parents and to improve nutritional status.

The nurse is providing care to a newborn with macrosomia who has sustained a midclavicular fracture. When reviewing the mother's labor and birth record, the nurse notes the following information: Breech birth Amniotomy APGAR score: 7 at 1 minute; 8 at 5 minutes Oxytocin augmentation Which information would the nurse correlate with the newborn's current injury? APGAR score: 7 at 1 minute; 8 at 5 minutes breech birth oxytocin augmentation amniotomy

breech birth Explanation: Midclavicular fractions most often occur during breech births or shoulder dystocia in newborns with macrosomia. Amniotomy or oxytocin augmentation are not associated with this type of fracture. The newborn's APGAR scores indicate a healthy newborn and are unrelated to the birth injury.

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis? positive Babinski and Moro reflexes cyanotic discoloration of the hands and feet frequent yawning and sneezing vigorous rooting and feeding

frequent yawning and sneezing Explanation: Manifestations of neonatal abstinence syndrome include: CNS dysfunction such as hyperactive reflexes resulting in exaggerated Babinski and Moro reflexes; hypertonic muscle tone and constant movement; metabolic, vasomotor, and respiratory disturbances with frequent yawning and sneezing; gastrointestinal dysfunction, including poor feeding; and frantic sucking or rooting. Acrocyanosis is a normal newborn finding which is cyanotic discoloration of the extremities.

The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus? suffer from asymmetrical intrauterine growth restriction have a serious birth defect grow to an unusually large size suffer from symmetrical intrauterine growth restriction

grow to an unusually large size Explanation: Maternal diabetes is the most widely known contributing factor to large-for-gestational-age newborns. LGA babies are frequently born to mothers with diabetes and poor glucose control. Continued high blood glucose levels in the mother lead to an increase in insulin production in the fetus. Increased insulin levels act as a fetal growth hormone causing macrosomia, an unusually large newborn with a birth weight of greater than 4,500 grams (9 pounds, 14 ounces). The incidence of birth defects in newborns born of a mother with gestational diabetes is not greatly increased. IUGR is not a typical outcome of uncontrolled gestational diabetes. It is more likely that the newborn will be large-for-gestational-age.

A newborn requires resuscitation secondary to asphyxia. The resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding? heart rate of 70 beats/min vigorous cry pink tongue respiratory rate 50 breaths/min

heart rate of 70 beats/min Explanation: Resuscitation is continued until the newborn has a heart rate higher than 100 beats/min, a good healthy cry, or good breathing efforts and a pink tongue. This last sign indicates a good oxygen supply to the brain.

A nursing student is learning about newborn congenital defects. The defect with symptoms that include a shiny scalp, dilated scalp veins, a bulging anterior fontanel (fontanelle), and eyes pushed downward with the sclera visible above the irises is which defect? hydrocephalus coarctation of the aorta spina bifida septal defect

hydrocephalus Explanation: Hydrocephalus has the clinical manifestations of a larger head than normal with widening cranial sutures. As the head enlarges, the suture lines separate, and the spaces are felt through the scalp. The anterior fontanel (fontanelle) becomes tense and bulging, the skull enlarges, the scalp becomes shiny, and its veins dilate. If pressure continues, the eyes appear to be pushed downward slightly and the sclera is visible above the irises. Spina bifida is a defect in the neural arch and is a failure of the posterior laminae of the vertebrae to close. Both septal defect and coarctation are both defects that involve the heart.

A neonate undergoing phototherapy treatment must be monitored for which adverse effect? increased insensible water loss severe decrease in platelet count increased GI transit time hyperglycemia

increased insensible water loss Explanation: Increased insensible water loss is due to absorbed photon energy from the lights. Hyperglycemia isn't a characteristic effect of phototherapy treatment. Phototherapy may cause a mild decrease in platelet count. GI transit time may decrease with the use of phototherapy.

What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? jaundice development tremor activity hyperglycemia phenylketonuria

jaundice development Explanation: A direct Coombs test is done to identify hemolytic disease of the newborn; positive results indicate that the newborn's red blood cells have been coated with antibodies and thus are sensitized. The Coombs test is frequently used in the evaluation of a jaundiced infant. Phenylketonuria (PKU) is a genetic disorder in which the body cannot process part of a protein called phenylalanine.

A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn? diaphragmatic hernia meconium aspiration syndrome pneumonia choanal atresia

meconium aspiration syndrome Explanation: The nurse should assess for meconium aspiration syndrome in the newborn. Meconium aspiration involves patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis that can be seen through chest X-rays. Direct visualization of the vocal cords for meconium staining using a laryngoscope can confirm aspiration. Lung auscultation typically reveals coarse crackles and rhonchi. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Newborns with choanal atresia, diaphragmatic hernia, and pneumonia do not exhibit these manifestations.

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? midclavicular fracture fracture of a rib fracture of the femur fracture of the tibia

midclavicular fracture Explanation: Trauma to the newborn may result from the use of mechanical forces, such as forceps during birth. Primarily injuries are found in large babies and babies with shoulder dystocia. Associated traumatic injuries include fracture of the clavicle or humerus or subluxations of the shoulder or cervical spine.

Which medication would be included in the plan of care for a newborn with acute neonatal abstinence syndrome who is not responding to conservative nursing approaches? morphine sulphate naloxone diazepam duragesic

morphine sulphate Explanation: Pharmacologic treatment is warranted for NAS if conservative measures are not adequate. For newborns with confirmed drug exposure, drug therapy is indicated if the newborn has acute NAS. Common medications used in the management of newborn withdrawal include an opioid (morphine or methadone), and phenobarbital is the second drug if the opiate does not adequately control symptoms.

The use of breast milk for premature neonates helps prevent which condition? Down syndrome necrotizing enterocolitis infantile respiratory distress syndrome Turner syndrome

necrotizing enterocolitis Explanation: Components specific to breast milk have been shown to lower the incidence of necrotizing enterocolitis in premature neonates. Infantile respiratory distress syndrome isn't directly influenced by breast milk or breastfeeding. Down syndrome and Turner syndrome are genetic defects and aren't influenced by breast milk.

The nurse should carefully monitor which neonate for hyperbilirubinemia? neonate of an Rh-positive mother neonate of African descent neonate with ABO incompatibility neonate with Apgar scores 9 and 10 at 1 and 5 minutes

neonate with ABO incompatibility Explanation: The mother's blood type, which is different from the neonate's, has an impact on the neonate's bilirubin level due to the antigen antibody reaction. Neonates of African descent tend to have lower mean levels of bilirubin. Chinese, Japanese, Korean, and Greek neonates tend to have higher incidences of hyperbilirubinemia. Neonates of Rh-negative, not Rh-positive, mothers tend to have hyperbilirubinemia. Low Apgar scores may indicate a risk for hyperbilirubinemia; 9 and 10 associate with normal adjustment to extrauterine life.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? newborn who is type O, father who is type A newborn who is type A, father who is type O newborn who is type A, mother who is type O newborn who is type O, mother who is type O

newborn who is type A, mother who is type O Explanation: Hemolytic disease of the newborn may develop when a mother and the unborn fetus have different blood types. The disease occurs when the immune system of the mother sees the fetus's red blood cells as foreign. Antibodies then develop against the fetus's red blood cells. These antibodies attack the red blood cells beginning at birth, causing them to break down too early. There is more than one way in which the fetus's blood type may not match the mother's. Commonly, it is the result of ABO incompatibility. It also occurs with Rh factor incompatibility. Of the options provided, the newborn with type A and the mother with type O will result in hemolytic disease of the newborn.

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth? cataracts nystagmus retinopathy amblyopia

retinopathy Explanation: Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn. Cataracts is common among older adults and results from the lens becoming opaque. Amblyopia, or lazy eye, is not related to gestational age and is assessed when the child is a toddler. Nystagmus is also not related to gestational age but to neurologic dysfunction of the eye.

Which sign appears early in a neonate with respiratory distress syndrome? pale gray skin color poor capillary filling time (3 to 4 seconds) bilateral crackles tachypnea more than 60 breaths/minute

tachypnea more than 60 breaths/minute Explanation: Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. Crackles occur as the respiratory distress progressively worsens. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen.

Which newborn would the nurse suspect to be most at risk for intellectual disability due to the mother's actions during pregnancy? the child of a client who admits to drinking a liter of alcohol daily during the pregnancy the child of a teenage client who used marijuana through her pregnancy to cope with stress the newborn of a client who used cocaine occasionally during her pregnancy the newborn of a client addicted to heroin and in the methadone maintenance program

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy Explanation: Fetal alcohol spectrum disorder is one of the most common known causes of intellectual disability. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects. The other illicit drugs are not linked to intellectual disability but have many other teratogenic effects on the fetus/newborn. Marijuana has not shown to have teratogenic effects on the fetus.

The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity? the endocrine system the respiratory system the genitourinary system the musculoskeletal system

the respiratory system Explanation: Immaturity causes difficulties involving all body systems, the most critical of which is the respiratory system, the last to fully develop. Typically, respirations are shallow, rapid, and irregular with periods of apnea (absence of breathing) that lasts for at least 20 seconds or that causes cyanosis and/or bradycardia. Although difficulties may occur in the other systems, the most critical is the respiratory system.

A 36-week neonate born weighing 1,800 g has microcephaly and microphthalmia. Based on these findings, which risk factor might be expected in the maternal history? use of marijuana use of alcohol positive group B streptococci gestational diabetes

use of alcohol Explanation: The most common sign of the effects of alcohol on fetal development is restricted growth in weight, length, and head circumference. Intrauterine growth restriction is not characteristic of marijuana use. Gestational diabetes usually produces large-for-gestational-age neonates. Positive group B streptococcus is not a relevant risk factor.

A nurse in a local health care facility is caring for a newborn with periventricular hemorrhage/intraventricular hemorrhage (PVH/IVH), who has recently been discharged from a local NICU. For which likely complications should the nurse assess? Select all that apply. vision or hearing deficits cerebral palsy acid-base imbalances hydrocephalus pneumonitis

vision or hearing deficits cerebral palsy hydrocephalus Explanation: A nurse should associate obstructive hydrocephalus, vision or hearing defects, and cerebral palsy with newborns who had a PVH/IVH. Acid-base imbalances are complications occurring during exchange transfusion for lowering serum bilirubin levels. Pneumonitis is a complication associated with esophageal atresia.

An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess? white sclera showing above the pupils a soft, fretful cry excessive thirst hypothermia in the late afternoon

white sclera showing above the pupils Explanation: As accumulating cerebrospinal fluid puts pressure on the posterior surface of the eye globes, they tip downward; white sclera shows above the pupils.