Chapter 23

The nurse is caring for a preterm neonate on an apnea monitor. When the monitor alarms, what action does the nurse take? Select all that apply. Begins bag and mask ventilation Silences the alarm Administers a dose of caffeine Performs a focused assessment of the neonate Counts the respiratory rate for a full minute SUBMIT ANSWER

Performs a focused assessment of the neonate Silences the alarm Counts the respiratory rate for a full minute

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? Administer epinephrine. Prepare to insert an endotracheal tube (ETT). Place the newborn's head in a neutral position. Hyperextend the newborn's neck.

Place the newborn's head in a neutral position.

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority? Prepare for repeat hematocrit levels q12h. Review maternal history for bleeding disorders. Continue to monitor blood glucose levels q6h. Prepare for continued positive airway pressure.

Prepare for repeat hematocrit levels q12h.

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

Preventing hypoglycemia with early feedings

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next? Suction the mouth then the nose. Give 3 compressions with 1 breath every 3 seconds. Suction the nose then the mouth. Ventilate at a rate of 40 to 60 breaths per minu

Suction the mouth then the nose.

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply. female fetus history of microsomic infant multiparity diabetes mellitus history of postdates gestation

multiparity diabetes mellitus history of postdates gestation

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply. Palpate for abdominal rigidity. Monitor blood pressure. Monitor urine output. Auscultate for bilateral breath sounds. Observe for bleeding.

Monitor urine output. Observe for bleeding.

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions? when no spontaneous respiratory effort is visible when the pulse oximetry reading is less than 80% when the heart rate is less than 60 beats per minute when there is no cardiac activity detectable

when the heart rate is less than 60 beats per minute

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response? "Your baby is not feeling pain but irritated with all the handling." "The fussiness will go away shortly with tight swaddling." "Offer your baby a feeding of sterile water solution by bottle." "You can give your baby a sucrose solution by bottle for pain relief."

"You can give your baby a sucrose solution by bottle for pain relief."

The nurse is assisting parents who have just experienced the death of their twin infants. What would be the most appropriate action for the nurse? Call the hospital clergy to initiate prayers with the parents. Encourage the parents to avoid exposure to their infants' medical care. Encourage the father to support his wife by allowing her to cry and grieve. Allow the parents to be present at medical rounds and the resuscitation.

Allow the parents to be present at medical rounds and the resuscitation.

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

BMI 17.5 prenatal history homelessness prenatal care

The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would the nurse expect to communicate about this newborn? Select all that apply. Narrow skull sutures Dry or thin umbilical cord Poor muscle tone over buttocks Sunken abdomen Increased subcutaneous fat stores

Dry or thin umbilical cord Poor muscle tone over buttocks Sunken abdomen

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant? Open the airway, suction the trachea, and administer oxygen. Open the airway, initiate respirations, and dry the infant. Dry the infant, administer blow-by oxygen, and keep the infant warm. Dry the infant, stimulate the infant, and keep the infant warm.

Dry the infant, stimulate the infant, and keep the infant warm.

The nurse is teaching a prenatal class emphasizing factors that pregnant mothers can implement to ensure a healthy newborn. Which nursing recommendations would be important to discuss? Select all that apply. Keep all prenatal checkups. Ensure good birth control plans. Have good blood sugar control. Visit the dentist regularly. Avoid the use of any types drugs and alcohol.

Keep all prenatal checkups. Have good blood sugar control. Avoid the use of any types drugs and alcohol. Visit the dentist regularly.

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia? Maintain adequate cardiac activity. Maintain adequate thermoregulation. Maintain adequate cerebral perfusion. Maintain adequate respirations.

Maintain adequate respirations.

A newborn is being admitted to the intensive care unit with the diagnosis of postterm infant. Which nursing actions would be the priority? Select all that apply. Initiate blood glucose monitoring. Monitor for hematocrit levels. Assess for jaundice. Check for Rh incompatibility. Observe for hypothermia.

Monitor for hematocrit levels. Assess for jaundice. Initiate blood glucose monitoring.

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform? Ballard assessment Moro assessment suck assessment Dubowitz assessment

Moro assessment

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

Offer to pray with the family if appropriate. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Respect variations in the family's spiritual needs and readiness.

Which result of a biophysical profile would indicate to the nurse that the fetus might tolerate labor poorly? Select all that apply. placental grade III a nonreactive nonstress test (NST) low amniotic fluid volume a positive stress test poor fundal growth

a nonreactive nonstress test (NST) low amniotic fluid volume placental grade III

The obstetrical nurse admits a premature, small-for-gestational age infant to the observational unit for assessment. The maternal record reveals an obese 27-year-old homeless woman with limited prenatal, medical, or dental care. Her blood pressure on admission was 170/90 mm Hg. Which factors in the maternal history would have suggested a high-risk pregnancy? Select all that apply. homelessness periodontal disease lack of prenatal care obesity maternal hypertension maternal age

lack of prenatal care homelessness periodontal disease maternal hypertension obesity

At birth, an infant is below average in weight, length, and head circumference and has a high hematocrit level. Which problem would the nurse assess for in this infant? Select all that apply. cold stress caput succedaneum prolonged acrocyanosis low glucose level high bilirubin level

low glucose level high bilirubin level prolonged acrocyanosis cold stress

A neonate is being admitted to the observational nursery with the diagnosis of postmaturity. What would the nurse expect to find with this gestational age variation? Select all that apply. abundant vernix caseosa abundant lanugo meconium-stained skin and fingernails few sole creases thin umbilical cord decreased breast tissue peeling, wrinkled skin

meconium-stained skin and fingernails thin umbilical cord peeling, wrinkled skin

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn? shiny heels and palms scant coating of vernix paper-thin eyelids closely approximated labia

shiny heels and palms

A preterm infant of 32 weeks' gestation is admitted from the birth suite to the neonatal intensive care unit with symptoms of respiratory distress. What would the nurse expect to see during assessments? Select all that apply. PaO2 35 pH 7 heart rate 110 bpm temperature 99.5° F (37.5° C) PaCO2 54 mm Hg respiratory rate 34 breaths/minute

pH 7 PaCO2 54 mm Hg PaO2 35

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response? "Your baby is just more irritable from the procedures." "Premature babies like yours will not feel pain yet." "The pain receptors in the brain are not sensitive to it like adults are." "Your baby is more sensitive to the pain than adults are."

"Your baby is more sensitive to the pain than adults are.

A newborn is returned to the newborn observational nursery demonstrating signs of cold stress after a prolonged bath. Which action would be a priority for the nurse? Request arterial blood gases. Assess feeding patterns. Perform a neurological assessment. Assess blood sugar level.

Assess blood sugar level.

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

Assess the axillary temperature every hour. Review maternal history. Assess environment for sources of heat loss. Encourage skin-to-skin contact.

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem? Inspect for retractions. Obtain a blood gas. Palpate for crepitus. Auscultate breath sounds.

Auscultate breath sounds.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion? Breastfeeding attempts will be enhanced. There will be a decrease in episodes of apnea. The infant will adjust better to the environment. The infant will have more awake periods.

Breastfeeding attempts will be enhanced.

What is the correct sequence of events in a neonatal resuscitation? Initiate ventilation, expand the lungs, dry the infant, and establish an airway. Dry the infant, establish an airway, expand the lungs, and initiate ventilation. Expand the lungs, establish an airway, initiate ventilation, and warm the infant. Warm the infant, establish an airway, initiate ventilation, and expand the lungs.

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. Offer early feedings. Administer vitamin supplements. Increase the infant's hydration. Initiate phototherapy. Stop breastfeeding until jaundice resolves.

Increase the infant's hydration. Offer early feedings. Initiate phototherapy.

The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate? Insert an orogastric tube. Begin cardiac compressions. Place an umbilical artery catheter. Raise the concentration of oxygen.

Insert an orogastric tube.

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? Assess the newborn's temperature every 8 hours until stable. Set the temperature of the radiant warmer at a fixed level. Observe for clinical signs of cold stress such as weak cry. Check the blood pressure of the infant every 2 hours.

Observe for clinical signs of cold stress such as weak cry.

A preterm infant with enteral tube feedings is being monitored for weight gain. What would be priorities for the nurse to include in the infant's plan of care? Select all that apply. Monitor Coombs results. Measure daily intake and output. Weigh daily. Assess for dehydration. Monitor weight weekly. Measure abdominal girth AC. Assess serum electrolytes.

Weigh daily. Measure daily intake and output. Assess serum electrolytes. Assess for dehydration. Measure abdominal girth AC.

A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state? trisomy 18 TORCH infection abnormal cord insertion maternal malnutrition

abnormal cord insertion

The nurse is providing bag and mask ventilation during newborn resuscitation. What assessment data will the nurse collect to evaluate the effectiveness of this action? Select all that apply. blood pressure greater than 50/30 mm Hg distal extremities are pink presence of bilateral breath sounds heart rate greater than 100 bpm adequate pulse oximetry readings

adequate pulse oximetry readings presence of bilateral breath sounds heart rate greater than 100 bpm

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of: increased production of red blood cells. aging placenta. loss of subcutaneous fat. hypoxia from cord compression.

aging placenta.

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication? infection atelectasis hypoglycemia intracranial hemorrhage

atelectasis

Which factors in a maternal birth record are risks for fetal growth restriction? premature rupture of membranes, gestational diabetes, or multiparity twin pregnancy, gestational diabetes, or essential hypertension renal disease, maternal age over 35, or congenital malformations congenital malformations, infections, or placental insufficiency

congenital malformations, infections, or placental insufficiency

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply. removing tape gently from the skin encouraging kangaroo care during procedures covering the newborn loosely with a blanket increasing the volume on device alarms using cool blankets to soothe the newborn

encouraging kangaroo care during procedures removing tape gently from the skin

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

facial grimacing with movement bruising over area asymmetrical movement edema present

Which nursing interventions promote healthy development of the preterm neonate? Select all that apply. nesting nonnutritive sucking covering the incubator quiet hours supine sleep position

nesting nonnutritive sucking quiet hours covering the incubator

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. monitor urinary output provide early feedings to prevent hypoglycemia obtain hemoglobin and hematocrit laboratory tests maintain oxygen saturation parameters insert a peripheral IV

obtain hemoglobin and hematocrit laboratory tests provide early feedings to prevent hypoglycemia maintain oxygen saturation parameters monitor urinary output

A preterm infant receives surfactant by lung lavage. Which interventions should the nurse perform immediately? Select all that apply. placing the infant in an upright position placing the infant in a prone position not suctioning the airway placing the infant in a supine position frequent suctioning of secretions

placing the infant in an upright position not suctioning the airway

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. asthma exacerbations during pregnancy smoking during pregnancy pregnancy weight gain of 25 lb (11 kg) hypotension upon admission drug use

smoking during pregnancy asthma exacerbations during pregnancy drug use

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess? absent lanugo creases on entire soles of feet thick umbilical cord meconium-stained skin

thick umbilical cord