Chapter 23
A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?
The supply of brown adipose tissue is not developed.
A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being
large-for-gestational-age.
A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?
atelectasis
Which factors in a maternal birth record are risks for fetal growth restriction?
congenital malformations, infections, or placental insufficiency
A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?
Administer 0.5 ml/kg/hr of breast milk enterally.
At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?
Alveolar collapse on expiration
The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?
undescended testes
The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?
Clustering care and activities
What is a consequence of hypothermia in a newborn?
holds breath 25 seconds
How does the nurse position the infant experiencing respiratory difficulty?
on the back with the head elevated 15 degrees
Which statement by the parents is evidence of meeting the desired outcome for a nursing diagnosis of impaired parenting?
"I'm so happy to hold you; I think you like it too."
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?
100 mm Hg
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood
A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply.
Monitor urine output. Observe for bleeding.
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.
The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?
To detect rebound hypoglycemia
What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?
ability to tolerate early oral feeding
The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?
Blood flows from the aorta to the pulmonary artery.
The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?
Radiation
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?
Dry the infant, stimulate the infant, and keep the infant warm.
The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate?
Insert an orogastric tube.
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?
Moro assessment
When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?
Preventing hypoglycemia with early feedings
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?
Provide a mobile the child can see no matter how the child is turned.
What percentage of neonates require some type of assistance to transition to extrauterine life?
10%
The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?
Alveolar collapse on expiration
Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?
Assess for decrease in urinary output.
During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.
0.3
A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?
40 to 60 breaths per minute
The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?
The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.
What is the correct sequence of events in a neonatal resuscitation?
Dry the infant, establish an airway, expand the lungs, and initiate ventilation.
When preparing to resuscitate a preterm newborn, the nurse would perform which action first?
Place the newborn's head in a neutral position.
A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?
The neonate is small for its gestational age.
A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?
A 24 cal/oz infant formula.
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."
In an infant who has hypothermia, what would be an appropriate nursing diagnosis?
Impaired tissue perfusion
At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?
Maintain adequate respirations.
Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?
Observe for clinical signs of cold stress such as weak cry.
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.
diabetes mellitus multiparity history of postdates gestation
Which assessment finding by the nurse would indicate that a neonate is being comforted?
increased oxygen saturation
A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight?
less than 1,500 g
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.
maternal smoking during pregnancy asthma exacerbations during pregnancy drug abuse
The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?
polycythemia
The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?
"A late preterm newborn may have more clinical problems compared with full-term newborns."
At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?
"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."
A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?
Administer dextrose intravenously.
A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?
Hearing assessment
A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?
The newborn may look wrinkled and old at birth.
A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?
fontanels
The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?
"We will need to plan for special care to help with learning disabilities."
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?
"You can give your baby a sucrose solution by bottle for pain relief."
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 more sensitive to the pain than adults are."
A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?
Basic immunizations are given according to the chronologic age of an infant.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?
Begin early feedings either by the breast or bottle.
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.
The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?
Closely monitor temperature.
A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?
Continue bag and mask ventilation only.
A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?
Ensure that the infant is kept warm.
A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?
Focus on decreasing blood viscosity by increasing fluid volume.
An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?
RDS is caused by a lack of alveolar surfactant.
A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?
RoP
At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?
The infant was a preterm, low birth weight and small for gestational age
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?
The pinna of the ear is soft and flat and stays folded.
A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?
With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?
Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."
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?
abnormal cord insertion
When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?
above 90th percentile
A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of:
aging placenta.
During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?
asymmetrical movement
A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:
chest rises with each bag compression.
The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?
dehydration
What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.
expiratory grunting nasal flaring retractions tachypnea
A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment?
hematocrit: 80%
An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?
hydrocephalus
A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?
increased amounts of vernix
An infant that is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions
A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?
intubation and suctioning of the trachea
The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?
jitteriness
A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?
lack of body posturing
A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?
meconium aspiration in utero or at birth
Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?
meconium stained fluids followed by tachypnea
The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?
meconium-stained skin and fingernails
After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?
necrotizing enterocolitis
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?
newly born preterm infant
Losing a newborn is perhaps one of the most difficult situations for a family. Which action by the nurse would be the most appropriate if a newborn dies?
offering mementos to the family of the newborn
To administer oxygen by bag and mask to a newborn, you would position the baby
on the back with the head slightly extended.
A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?
paternal factors
A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?
peeling and wrinkling of the neonate's epidermis
The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?
placental factors
When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?
rocking and massaging
Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment?
stabilized respiratory effort
Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?
tea-colored urine
The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?
thick umbilical cord
The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?
to develop trust in people
A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:
very low birth weight.
An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?
when the heart rate is less than 60 beats per minute
A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?
0.5 to 1 mL/kg/h
The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?
20th
The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?
30 mg/dL
A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?
Less than 1,000 g.
The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.
Poor skin turgor Sparse or absent hair Diminished muscle tissue
A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.
clay-colored stools tea-colored urine increased serum bilirubin levels
A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?
head larger than body
The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?
polycythemia, probably due to chronic fetal hypoxia
At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?
postterm
A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?
respiratory distress syndrome
Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?
respiratory rate of 60 to 70 bpm
A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:
term
A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?
the pressure the nurse uses when the hand squeezes against the bag
The nurse determines a newborn is small-for-gestational age based on which characteristics?
wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores
The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?
Begin supervised feedings for the newborn.
The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?
22 calories per ounce
A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?
Auscultate breath sounds.
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 hematocit levels q12h.
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:
ductus arteriosus remains open.
A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.
placing the infant in an upright position not suctioning the airway