Chapter 24

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

Application of eye dressings to the infant

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation? Infant is crying. Infant is quiet. Infant is kicking feet. Infant has hand in mouth.

Infant has hand in mouth.

A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed. Which type of specimen should the nurse collect to obtain the most accurate results? Meconium Blood Urine Sputum

Meconium

Which teaching is most helpful in preventing sudden infant death syndrome (SIDS)? Burp the infant before laying him or her down. Place the infant on the back for sleep. Place stuffed animals in the crib for stimulation. Use a nursery monitor to hear the infant cry.

Place the infant on the back for sleep.

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

Serial blood glucose levels

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? The skin is pale, and no vessels show through it. Creases appear on the interior two-thirds of the sole. The pinna of the ear is soft and flat and stays folded. The neonate has 7 to 10 mm of breast tissue.

The pinna of the ear is soft and flat and stays folded.

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? a sudden drop in hematocrit soft, flat anterior fontanels (fontanelles) pink skin with noted blue extremities intake and output for 8 hours

a sudden drop in hematocrit

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 temperature instability seizures feeble sucking

asymmetrical movement

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 clear the airway suction the throat prepare for endotracheal intubation

clear the airway

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

diminished peripheral pulses

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings? cleft palate esophageal atresia cleft lip coarctation of the aorta

esophageal atresia Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens, no feedings should be given until the newborn has been examined.

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes. The nurse anticipates that the newborn is at risk for being: large-for-gestational-age. small-for-gestational-age. appropriate-for-gestational-age. very-large-for-gestational-age.

large-for-gestational-age.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? gaze aversion hiccups quiet, alert state yawning

quiet, alert state

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis? abundant sole creases minimal vernix caseosa breasts clearly delineated undescended testes

undescended testes

Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks." "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." "Some women don't have any problem giving birth to large babies. You might want to get a second opinion."

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."

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? "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." "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."

"Being able to most likely correct this in one stage rather than several is reassuring."

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? "Yes, as they lack the antibody called IdD that acts as protection from infections." "Not really, as premature infants are cared for in an isolate, protecting them from infection." "Feeding premature infants breast milk establishes the best protective mechanisms." "That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

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

Place the isolette in a quiet area of the nursery.

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

Speak softly to the infant. Keep lights low in the nursery. Coordinate nursing care.

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 occulta Spina bifida major Spina bifida with meningocele Spina bifida with myelomeningocele

Spina bifida with myelomeningocele

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 must have had a long labor. The infant's mother probably had diabetes. The infant may have experienced birth trauma. The infant may have been exposed to alcohol during pregnancy.

The infant's mother probably had diabetes.

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? colostomy intravenous fluids nasal cannula for oxygen nasogastric tube

colostomy

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? evaporation convection radiation conduction

conduction

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. hydrocephalus acid-base imbalances pneumonitis vision or hearing deficits cerebral palsy

hydrocephalus vision or hearing deficits cerebral palsy

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis? meconium-stained skin and fingernails abundant vernix caseosa and lanugo Wharton's jelly few creases on soles

meconium-stained skin and fingernails