Exam 4 Maternity

The nurse is educating a group of new mothers about the use of pacifiers for their infants. Which statement does the nurse include in the teaching? "Pacifiers should be: 1 Designed and prepared at home." 2 Reinserted once the infant falls asleep." 3 Coated with any type of sweet solution." 4 Constructed as one piece with a shield."

Constructed as one piece with a shield." Pacifiers that are made of one piece and include a shield or flange large enough to prevent entry into the mouth with a handle can be used safely. Homemade pacifiers may not be perfectly designed and may pose danger to the infant, because the entire object or a portion may lodge into the pharynx. The pacifiers should not be reinserted into the mouth of the infant once the infant falls asleep, because it may disturb the infant's sleep. Pacifiers should not be coated with any type of sweet solution.

The nurse observes that a newborn is passing stool through the vagina. What does the nurse infer from this observation? The newborn has: 1 Epispadias. 2 Hypospadias. 3 Vaginal agenesis. 4 Rectovaginal fistula.

Rectovaginal fistula. Fecal discharge from the vagina indicates a rectovaginal fistula. Hypospadias or epispadias are abnormalities of the male genitalia. All female infants are born with hymenal tags; absence of such tags can indicate vaginal agenesis and is associated with adrenal hyperplasia.

The nurse is taking care of a newborn who is not yet circumcised. Which anesthetic agent does the nurse expect the primary health care provider to prescribe? 1 4% lidocaine (LMX4) 2 Hyoscyamine (Symax) 3 Morphine (Morphine) 4 Atracurium (Tracrium)

4% lidocaine (LMX4) Eutectic mixture of 4% lidocaine (LMX4) is given as a topical anesthetic to the circumcised newborn. Hyoscyamine is used to provide symptomatic relief in various gastrointestinal disorders, such as spasms, peptic ulcers, irritable bowel syndrome, diverticulitis, pancreatitis, colic, and cystitis. Morphine is primarily used to treat both acute and chronic severe pain in a circumcised patient. It is also used to manage pain caused by myocardial infarction and labor. Atracurium (Tracrium) is a muscle relaxant used during circumcision, not before the surgery.

A patient who used cocaine during pregnancy asks the nurse about feeding the infant. The infant is being treated for cocaine withdrawal symptoms. After further discussion, the nurse finds that the patient is not willing to participate in the drug rehabilitation program and still uses cocaine frequently. What does the nurse instruct the patient related to infant nutrition? 1 "Breastfeeding may be good for the child." 2 "Avoid using infant formulas for the child." 3 "Avoid breastfeeding the child." 4 "The child needs parenteral nutrition."

"Avoid breastfeeding the child." The nurse instructs the parent to avoid breastfeeding the infant because significant amounts of cocaine are found in breast milk. Breastfeeding may expose the child to further complications. The nurse encourages the parent to use infant formulas because they are safe for the infant. Parenteral nutrition is not needed unless the infant is unable to feed orally.

Which information about feeding does the nurse provide to the parent of a preterm infant with respiratory dysfunction syndrome? 1 "Avoid gavage feedings in your infant." 2 "Breastfeed your infant every 3 hours." 3 "Enteral feeding will not be beneficial." 4 "Parenteral therapy is unsafe."

"Avoid gavage feedings in your infant." The nurse instructs the parent to avoid gavage feedings because they increase the respiratory rate and subject the infant to risk for respiratory distress. Breastfeeding is avoided because it also increases the risk for respiratory distress in the infant. Enteral feeding is beneficial because it helps enhance maturation of the infant's gastrointestinal system. Parenteral therapy is the safest way of feeding during the acute stage of the syndrome.

Which dietary instruction does the nurse give to the parents of a child with phenylketonuria? 1 "Avoid meat and dairy products in the child's diet." 2 "Include fruits and vegetables in the child's diet." 3 "Use artificial sweeteners instead of sugar." 4 "Include breads and hamburgers in child's diet."

"Avoid meat and dairy products in the child's diet." Meat and dairy products contain high protein levels, which increase phenylalanine levels. Therefore the nurse instructs the patient to eliminate these foods from the child's diet. Telling the patients to include any fruits and vegetables in the diet will be unsafe, because some fruits may have high phenylalanine levels. Therefore the nurse needs to provide the patient with a proper food list. Artificial sweeteners are not safe for a child, because they contain phenylalanine. Breads and hamburgers have low phenylalanine levels. However they need to be measured to prevent high amounts of phenylalanine in the blood.

What discharge instructions are given to the parents of an infant with facial paralysis? 1 "You need to administer eyedrops daily." 2 "You must avoid breastfeeding the child." 3 "You must initiate range-of-motion exercises." 4 "Always position the child on the affected side."

"You need to administer eyedrops daily." In an infant with facial paralysis, sometimes the eyelid on the affected side does not close completely. Hence the nurse instructs the parents to instill eyedrops in the eyes daily to prevent drying of the conjunctiva, sclera, and cornea. The parent can breastfeed the child with assistance to help the infant grasp and compress the areolar area. Range-of-motion exercises are not necessary in facial palsy; they are necessary for an infant with brachial palsy. It is not necessary to place an infant with facial palsy on the affected side; however, in an infant with phrenic nerve palsy, placing the infant on the affected side will facilitate maximum expansion of the uninvolved lung.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. 1. Lubricate the tip of the tube with sterile water. 2. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. 3. Check placement of the NG tube by aspirating gastric contents. 4. Gently insert the NG tube through the mouth or nose.

1. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. Correct 2. Lubricate the tip of the tube with sterile water. Correct 3. Gently insert the NG tube through the mouth or nose. Correct 4. Check placement of the NG tube by aspirating gastric contents. The infant is place in a supine position. The NG tube is measured from the tip of the nose to the earlobe and to midpoint between the xiphoid process and the umbilicus. Tape may be used to mark the correct length on the tube. The tip of the tube is lubricated with sterile water and then is inserted through the mouth or nose. Placement of the tube is checked by aspirating gastric contents.

The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant? 1 9 hours after the infant is born 2 13 hours after the infant is born 3 14 hours after the infant is born 4 18 hours after the infant is born

9 hours after the infant is born If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within 12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth, not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than 2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.

After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh skinfolds and uneven knee levels. What does the nurse infer from this assessment? The infant had: 1 A low birth weight. 2 A vertex presentation at birth. 3 Amniotic prolapse before birth. 4 A breech presentation at birth.

A breech presentation at birth. The newborn was found to have asymmetric gluteal and thigh skinfolds and uneven knee levels, which indicate a positive Ortolani test. The test reveals that the infant has developmental dysplasia of the hips (DDH). DDH occurs more often in female infants with breech presentation at birth. Therefore the newborn had breech presentation before birth. Low birth weight may be due to gestational diabetes and preterm deliveries; however, low a low birth weight is unrelated to developmental dysplasia of the hips. Amniotic prolapse is not associated with uneven knee lengths and asymmetric gluteal and thigh skinfolds. Vertex presentation of the newborn is an edematous area that is present at birth, extends across suture lines of the skull, and usually disappears spontaneously within 3 to 4 days after birth.

Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings? 1 Epispadias 2 A ruptured viscus 3 A diaphragmatic hernia 4 Hirschsprung's disease

A diaphragmatic hernia The infant has a sunken abdomen (scaphoid) with bowel sounds heard in the chest. Nasal flaring and grunting indicate respiratory distress. All these symptoms indicate a diaphragmatic hernia. Epispadias, ruptured viscus, and Hirschsprung's disease are not associated with these symptoms. Epispadias is the condition where the urethral opening is located in an abnormal position. Ruptured viscus is due to abdominal distention at birth, caused by abdominal wall defects. Hirschsprung's disease is a congenital disorder that involves an imperforate anus.

The parents of a newborn infant asks the nurse about the Guthrie blood test that is prescribed for their infant. Which is the best response by the nurse? "The test helps: 1 Determine the infant's thyroid gland function." 2 Assess inborn errors of metabolism in the infant." 3 Assess whether the infant has phenylketonuria." 4 Determine whether the infant has elevated glucose levels."

Assess whether the infant has phenylketonuria." The Guthrie blood test is a bacterial inhibition assay for phenylalanine in the blood. Therefore the test helps detect the risk of phenylketonuria. Thyroid tests are prescribed to understand the infant's thyroid gland function. Inborn errors of metabolism are identified by tandem mass spectrometry. Blood glucose tests are prescribed for an infant to understand glucose levels.

In the special care nursery, the nurse is assigned to care for an infant now 18 hours old. Although there is nothing specific for the nurse to report to the pediatric hospitalist, a number of clinical manifestations may indicate early warning signs of neonatal sepsis. Upon reviewing the mother's record, the nurse identifies a prenatal fever and rupture of membranes 36 hours before admission. Which finding in the newborn's clinical presentation does the nurse find to be normal, rather than an indication of possible sepsis? 1 Grunting, nasal flaring 2 Increased oxygen saturation 3 Bradycardia 4 Temperature instability

Increased oxygen saturation Respiratory system manifestations of sepsis in the neonate include decreased O2 saturation, apnea, tachypnea, grunting, nasal flaring, retractions, and metabolic acidosis. Cardiovascular indicators include decreased cardiac output, tachycardia or bradycardia, hypotension, and decreased perfusion. Temperature instability, lethargy, hypotonia, irritability, and seizures are all central nervous system manifestations of sepsis. The earliest clinical signs of neonatal sepsis are characterized by their lack of specificity. If a thorough assessment of the infant indicates possible sepsis, the physician should be notified in order for appropriate laboratory work to be ordered.

Which is a priority nursing intervention for an infant born to a patient with poorly controlled diabetes? 1 Initiating dextrose infusion 2 Evaluating urine reports 3 Encouraging breastfeeding 4 Initiating exchange transfusion

Initiating dextrose infusion The blood glucose levels of an infant born to a mother with poorly controlled diabetes are very low. Therefore the nurse administers an infusion of 10% dextrose and water intravenously to maintain serum blood glucose levels between 40 and 50 mg/dL. Evaluating urine reports is not a priority in this case if the blood serum reports indicate hypoglycemia. Breastfeeding may not be feasible if the infant's cardiorespiratory condition is not stable. Exchange transfusion is a priority in an infant with a hemolytic disease.

While teaching breastfeeding techniques to a postpartum patient, the nurse advises the patient to check whether the infant's cheeks are rounded or dimpled during feeding. What is the reason for giving such advice to the patient? 1 It prevents nipple trauma. 2 It may help prevent trauma to the infant's jaws. 3 It indicates the effectiveness of breastfeeding. 4 It helps the infant latch onto the nipples.

It indicates the effectiveness of breastfeeding. Usually during sucking, the infant's cheeks become rounded and are not dimpled, so the shape of the baby's cheeks indicates the effectiveness of feeding. Nipple trauma can be prevented by inserting a finger in the side of baby's mouth to break the suction. Trauma to the infant's jaw is not associated with rounded cheeks. Placing the nipple on the infant's lips helps the infant latch.

Which condition may be seen in a newborn infant affected by hemolytic disease? Select all that apply. 1 Jaundice 2 Anemia 3 Hypoglycemia 4 Macrosomia 5 Anencephaly

Jaundice Anemia Hypoglycemia The serum levels of unconjugated bilirubin rise rapidly in an infant with hemolytic disease after birth. The inability of the liver to conjugate and excrete the excess bilirubin results in jaundice in the infant. Anemia results from the hemolysis of large numbers of erythrocytes. Hypoglycemia may occur as a result of pancreatic cell hyperplasia. Macrosomia refers to excessive weight gain in the child after birth, most often seen in infants born to diabetic women. Anencephaly is a central nervous system anomaly seen in infants of diabetic mothers.

The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation? 1 Hypoxemia 2 Cardiac disorder 3 Nasal obstruction 4 Laryngeal obstruction

Nasal obstruction Newborns are generally nose breathers. After 3 weeks of age, newborns develop a reflex response that allows them to use their mouths for breathing at times of nasal obstruction. If the newborn has hypoxemia, the infant would breathe deeply through nose and not through the mouth. Mouth breathing in infants is a normal finding and does not indicate a cardiac problem. If the infant has laryngeal obstruction, the infant would be unable to breathe. This is a life-threatening condition.

Which intervention does the nurse include while providing care for a preterm infant with a soft cranium? 1 Places the infant on a soft mattress 2 Places the infant on a waterbed 3 Provides skin-to-skin (kangaroo) contact 4 Transfers the infant to a heated incubator

Places the infant on a waterbed A preterm infant with a soft cranium is at risk for deformation caused by positioning on a mattress. Therefore the nurse places the infant on a waterbed, which reduces the risk of cranial molding. A soft mattress may not prevent deformation because the cranium is subject to molding at slight pressures. Skin-to-skin (kangaroo) contact is initiated to prevent cold stress in an infant and help the infant maintain body temperature. The nurse transfers an infant to a heated incubator to maintain thermal stability.

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action? 1 Epispadias 2 Polydactyly 3 Polycythemia 4 Hyperbilirubinemia

Polycythemia Clamping the umbilical cord after 2 minutes of birth refers to delayed clamping. Delayed clamping of the cord results in polycythemia (greater plasma volume) and improves hematocrit and iron status. Polycythemia is more commonly observed in preterm infants than in term infants. Epispadias is an abnormal position of the urethral opening and is a congenital abnormality that is not associated with the umbilical cord. Polydactyly is the presence of extra digits on the extremities and is a congenital abnormality. Hyperbilirubinemia (increased bilirubin) is not related to delayed clamping of the umbilical cord, although it may lead to jaundice in the infant.

The clinical reports of a pregnant patient who is Rh negative indicate Rh(D) sensitization. Which nursing intervention is a priority in this case? 1 Administering RhIg, a human gamma globulin concentrate 2 Preparing the pregnant patient for phototherapy 3 Preparing the infant for intrauterine transfusion 4 Obtaining a prescription for phenobarbital (Luminal)

Preparing the infant for intrauterine transfusion Intrauterine transfusion in the infant helps treat hyperbilirubinemia and hydrops caused by Rh incompatibility. RhIg is administered to unsensitized Rh-negative mothers to prevent the development of maternal sensitization to the Rh factor. Phototherapy is most effective to decrease bilirubin level in the infant. Phenobarbital (Luminal) is used to decrease drug withdrawal effects in an infant exposed to a drug in the uterus.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: Select all that apply. 1 Prevent exposure to people with upper respiratory tract infections. 2 Keep the infant away from secondhand smoke. 3 Avoid loose bedding, waterbeds, and beanbag chairs. 4 Do not let the infant sleep on his or her back. 5 Keep a bulb suction available at home.

Prevent exposure to people with upper respiratory tract infections. Keep the infant away from secondhand smoke. Avoid loose bedding, waterbeds, and beanbag chairs. Keep a bulb suction available at home. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the mouth and nose at home to protect the airway.

Which interventions does the nurse implement while providing care for an infant with neonatal abstinence syndrome (NAS)? Select all that apply. 1 Provides dim lights in the room 2 Reduces noise levels in the room 3 Avoids wrapping the infant tightly 4 Encourages the mother to breastfeed 5 Assesses the infant's skin regularly

Provides dim lights in the room Reduces noise levels in the room Encourages the mother to breastfeed Assesses the infant's skin regularly NAS refers to certain behaviors exhibited by infants who were exposed to drugs in the uterus. The nurse provides dim lights and reduces the noise levels in the infant's room to decrease hyperactivity and irritability in the infant. The nurse encourages breastfeeding to promote mother-infant bonding. The nurse assesses the infant's skin regularly, because rubbing on bed linens may cause skin breakdown in the infant. Wrapping tightly is beneficial because it limits the infant's ability to self-stimulate and decreases hyperactivity.

What precautions does the nurse take while providing skin care to a preterm infant? Select all that apply. 1 Uses alkaline-based soap to clean the skin 2 Rinses with water after using alcohol on the skin 3 Uses hydrocolloid adhesives on the skin 4 Uses small scissors to remove dressings 5 Avoids solvents to remove tape

Rinses with water after using alcohol on the skin Uses hydrocolloid adhesives on the skin Avoids solvents to remove tape The use of alcohol may cause severe irritation and chemical burns on the infant's skin. Therefore the nurse rinses the skin with water. Hydrocolloid adhesives are safe because they mold well to skin contours and adhere in moist conditions. Solvents are not used to remove tape, because they dry and burn the skin. Alkaline-based soap is not used, because it can destroy the acid mantle of the infant's skin. The use of scissors is unsafe, because they may snip off tiny extremities.

What does the nurse include in the plan of care of a high risk preterm infant? Select all that apply. 1 Routinely monitor blood pressure. 2 Assess intake and output records. 3 Assess for respiratory distress. 4 Maintain room temperature. 5 Encourage skin-to-skin (kangaroo) contact.

Routinely monitor blood pressure. Assess intake and output records. Assess for respiratory distress. Encourage skin-to-skin (kangaroo) contact. The nurse routinely monitors the infant's blood pressure to assess whether the values are increasing normally in the first month of life. Accurate intake and output records are necessary to understand the infant's fluid status. The preterm infant is at risk for respiratory distress. Therefore the nurse needs to assess the infant's respiratory function so that prompt actions can be taken. The nurse encourages the parents to provide skin-to-skin (kangaroo) contact with the infant to maintain thermal stability. A preterm infant needs application of external warmth. The room temperature may not be effective to maintain thermal stability. Therefore the infant is placed in a heated environment to prevent cold stress.

Which skeletal injuries does the nurse assess for in an infant after a difficult birth? Select all that apply. 1 Skull fractures 2 Clavicle fracture 3 Anencephaly 4 Macrosomia 5 Galactosemia

Skull fractures Clavicle fracture The infant may have a linear or depressed skull fracture from a difficult birth as a result of the pressure of the head on the bony pelvis. A clavicle fracture is sometimes seen in a difficult birth. There may be limited arm motion and an absence of the Moro reflex on the affected side. Anencephaly is a central nervous system anomaly seen in an infant of a diabetic mother. Macrosomia refers to excessive weight gain in the infant after birth, seen in the infants of diabetic mothers. Galactosemia is an autosomal recessive disorder.

The nurse tells a postpartum patient to gently massage her breasts before performing hand expression. Why the nurse did give such an instruction? Massage will: 1 Prevent nipple trauma. 2 Reduce body temperature. 3 Stimulate the let-down reflex. 4 Reduce pain during expression.

Stimulate the let-down reflex. Gentle massage before hand expression is recommended to stimulate the let-down reflex or milk ejection reflex, which increases milk production. This intervention is not useful to prevent nipple trauma, reduce body temperature, or reduce pain during expression. Nipple trauma can be prevented by placing the finger at the side of the infant's mouth to reduce the suction while separating the lips from the nipples. Body temperature and pain can be reduced by taking antipyretics or analgesics.

Which symptoms of septic shock are likely to be seen in a low-birth-weight infant with septicemia? Select all that apply. 1 Tachycardia 2 Hypotension 3 Hypoglycemia 4 Cool extremities 5 Respiratory distress

Tachycardia Hypotension Cool extremities Respiratory distress Tachycardia and hypotension may be observed in a low-birth-weight infant with septicemia, which indicates septic shock. Septic shock occurs when toxins are released into the bloodstream. Hence, the nurse must report immediately to the primary health care provider. The other indication of septic shock is cool extremities, which indicate poor perfusion and respiratory distress and should be promptly reported so that oxygen therapy can be started. Hypoglycemia is seen in an infant born to a diabetic patient due to elevated levels of insulin during pregnancy.

Which TORCH infection could be contracted by the infant because the mother owned a cat? 1 Toxoplasmosis 2 Varicella-zoster 3 Parvovirus B19 4 Rubella

Toxoplasmosis Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

Which is a priority nursing action while assessing an infant with rubella infection? 1 Wearing gloves before touching the infant 2 Evaluating the infant's blood reports 3 Evaluating the infant's urine reports 4 Washing the infant with warm water

Wearing gloves before touching the infant Rubella infection may easily transmit from one infant to the other if proper caution is not taken. Therefore the nurse wears gloves before touching the infant to avoid contact and prevent the risk of cross-contamination. The nurse evaluates the infant's blood and urine reports as a part of the assessment process. However, it is not a priority in this case. The nurse washes the infant with warm water after birth to remove the blood and meconium from the infant's body.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to: 1 listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify the physician. 2 continue to observe and make no changes until the saturations are 75%. 3 continue with the admission process to ensure that a thorough assessment is completed. 4 notify the parents that their infant is not doing well.

listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify the physician. Listening to breath sounds, ensuring the patency of the endotracheal tube, increasing oxygen, and notifying the physician are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%. The nurse should delay other tasks to stabilize the infant. Notifying the parents is not appropriate. Further assessment and intervention are warranted before determination of fetal status.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: 1 vision. 2 hearing. 3 smell. 4 taste.

vision. The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this? 1 "Are you applying A&D ointment while cleaning?" 2 "Are you cleaning the penis with lukewarm water?" 3 "Are you applying fresh petrolatum while cleaning?" 4 "Are you cleaning with prepackaged commercial wipes?"

"Are you cleaning with prepackaged commercial wipes?" Do not use prepackaged commercial baby wipes for cleaning the circumcised site because they can contain alcohol. Alcohol delays healing and also causes discomfort to the infant. The infant cries out loudly because of the discomfort. Washing the penis gently with lukewarm water is recommended to remove urine and feces. Fresh petrolatum is applied to reduce pain after each diaper change. The application of A&D ointment while cleaning is done to prevent the sticking of the penis to the discharge, as well as to increase the infant's comfort.

What does the nurse inform the parent of a preterm infant who has birth asphyxia and is at risk for necrotizing enterocolitis (NEC)? 1 "Breast milk will be given enterally." 2 "Probiotics are not given after birth." 3 "Report skin rashes immediately." 4 "Provide skin-to-skin (kangaroo) contact."

"Breast milk will be given enterally." Breast milk provides passive immunity, macrophages, and lysosomes to the infant and helps prevent NEC. Probiotics such as Lactobacillus acidophilus and Bifidobacterium infantis are given enterally to reduce the severity of NEC in infants after birth. Lethargy and abdominal distention, not skin rashes, are symptoms of NEC. Skin-to-skin care does not help prevent NEC and is used to help infants maintain thermal stability.

The student nurse asks the clinical instructor about changes in normal elimination patterns of infants. Which response given by the clinical instructor is most appropriate? 1 "Formula-fed infants pass more stools every day than breastfed infants." 2 "Formula-fed infants' stools are less offensive than breastfed infants' stools." 3 "Breastfed infants should pass stools three times a day for the first few weeks." 4 "The stools of formula-fed infants should resemble mustard mixed with cottage cheese."

"Breastfed infants should pass stools three times a day for the first few weeks." Breastfed infants should pass stools three times a day for the first few weeks. Any deviation from this indicates problems related to stooling. Formula-fed infants have fewer stools than breastfed infants. The formula-fed infants may have as few as one stool every other day after the first few weeks. The odor of the stools of formula-fed infants is more offensive than that of infants who are breastfed. The stools of breastfed infants are looser and resemble mustard mixed with cottage cheese.

Which statement by the nursing student about the prevention of health care-associated infections (HAIs) in a nursery unit indicates effective learning? 1 "Changing used equipment often may cause HAIs." 2 "Hand washing helps prevent HAIs in a nursery unit." 3 "Nursery visitors are allowed if they wear masks." 4 "Soiled diapers are kept far from the children's beds."

"Hand washing helps prevent HAIs in a nursery unit." Infants in the nursery unit are at a high risk for infections. Hence, the most effective way to prevent infection is effective hand washing. The equipment used for the infants, such as nasogastric and intravenous tubing, needs to be changed frequently because it may become contaminated and cause infections. Visitors should be instructed not to overcrowd the nursery and to wash their hands before entering. Keeping soiled diapers away from the children is not enough; only proper disposal will help prevent infections.

The nurse advises the patient to use a hospital-grade electric pump for effective feeding of a preterm infant. What does the nurse tell the patient about using this pump? 1 "Hospital-grade electric pumps can be used at any time after childbirth." 2 "Pumping should be done 8 to 10 times a day to maintain milk supply." 3 "Milk obtained by pumping should be microwaved immediately." 4 "Honey should be added to the milk obtained by pumping."

"Pumping should be done 8 to 10 times a day to maintain milk supply." Pumping by a hospital-grade electric pump is recommended 8 to 10 times a day to maintain milk supply. A lower rate of pumping will not maintain an adequate quantity of breast milk. Hospital-grade electric pumps should be used as soon as the baby is born to obtain the colostrum, which is important for growth. Milk obtained by pumping should be refrigerated immediately. Heating the milk may decrease its nutritional value. Breast milk is the best food for a preterm infant. It contains all necessary nutrients for the infant, so the patient should not add anything to the breast milk. Moreover, honey is known to cause botulism in infants and therefore should be avoided.

The nurse is teaching a student nurse about stool patterns of a breastfed infant. What statement made by the student nurse indicates the need for further teaching? 1 "Watery stools are considered normal." 2 "Green-colored stools are considered diarrhea." 3 "Stool would have a water ring in normal conditions." 4 "Stool frequency may be three times a day in normal condition."

"Stool would have a water ring in normal conditions." Stools in a normal breastfed neonate will not have a water ring. Presence of a water ring in a stool indicates that the infant has diarrhea. Watery stools are normal findings of breastfed neonates. Green-colored stool indicates diarrhea. A breastfed neonate has a stool frequency of more than three times per day.

What instruction does the nurse provide to parents of a preterm infant who has physiologic immaturity? 1 "The child will have irreparable physiologic deformities." 2 "The child may be vulnerable to fluid and electrolyte imbalances later." 3 "The infant may need neurologic and developmental interventions later." 4 "The infant will have attention deficit hyperactivity disorder (ADHD)."

"The infant may need neurologic and developmental interventions later." A preterm infant may have neurologic impairment after birth, which may result in behavioral and developmental problems later in life. Therefore the nurse instructs the parents that the infant may need neurologic and developmental interventions later. Telling the parents that the infant will have irreparable physiologic deformities will make the parents anxious. There may or may not be any deformities depending on the size and gestational age of infants at birth. Fluid and electrolyte imbalances are caused by fluid overload or dehydration and are treated with appropriate fluid replacement. The child may have ADHD or other neurologic problems depending on the degree of immaturity at birth.

The parent of a newborn reports to the nurse, "My baby has small, red papules on the face and hands." What response should the nurse give to the parent? 1 "The skin reaction is normal." 2 "The spots are due to cyanosis." 3 "The baby has adequate oxygen supply." 4 "The skin rash is due to direct sunlight exposure."

"The skin reaction is normal." The newborn has small, red papules on her face and hands that indicate transient rashes due to erythema toxicum. This condition is not clinically significant and does not require any treatment. Cyanosis is the appearance of a bluish tint on the skin, but it is not accompanied by small, red papules on the body. Adequate oxygen supply does not lead to small, red-colored papules on the skin. Exposure to direct sunlight does not lead to the formation of papule-like lesions on the skin.

What instruction does the nurse provide to parents of an infant who is being treated for galactosemia? 1 "You need to breastfeed the child often." 2 "Use lactose-free infant formulas." 3 "Report respiratory distress at once." 4 "Avoid any soy-protein formula."

"Use lactose-free infant formulas." Galactosemia occurs because of increased levels of galactose in the blood. Therefore the nurse instructs the parents to use lactose-free infant formulas for feeding. Breastfeeding is avoided because breast milk contains lactose. An infant with galactosemia experiences vomiting, diarrhea, and weight loss. Respiratory distress is not seen in a child with galactosemia. Soy-protein formula is safe and effective for the infant, and the nurse encourages its use.

While caring for a postpartum patient, the nurse finds that she is unable to feed her newborn on time because the baby spends most of the time sleeping. What should the nurse suggest to the patient in this situation? 1 "You can wake the baby up by gently massaging his back." 2 "Do not allow the baby to suck his thumb because it promotes sleep." 3 "Avoid swaddling the baby with a blanket because it prevents deep sleep in the baby." 4 "Store the expressed breast milk in a bottle and feed the baby when he wakes up."

"You can wake the baby up by gently massaging his back." Feeding the baby on time is difficult if the baby spends most of the time sleeping. The mother can wake the baby by gently massaging the back. Preventing thumb sucking will not help wake the baby. The baby should be properly covered with a blanket to prevent cold stress. The nurse should encourage the patient to feed the baby on time because it helps promote growth and development in the newborn. Therefore the nurse should not advise the patient to give stored milk to the baby.

The nurse is performing an evaluation and screening of a newborn. To estimate the blood glucose levels, the nurse collects blood from the infant by the heelstick method. What nursing intervention would be accurate while performing the heelstick method? Make a puncture no deeper than: 1 3 mm into the neonate's heel. 2 2.4 mm into the neonate's heel. 3 2 mm on the right side of the neonate's heel. 4 1 mm on the right side of the neonate's heel.

2.4 mm into the neonate's heel. To avoid necrotizing osteochondritis in the newborn, the puncture is made no deeper than 2.4 mm in the heel. Therefore making a puncture 2 mm deep in the heel is the correct intervention. If the puncture is made 3 mm deep into the heel, it would result in lancet penetration of the bone. Therefore the nurse would not make a puncture 3 mm deep. The heelstick method is performed in the heel, not on the sides of the heel. Therefore making a puncture that is 2 mm or 1 mm deep on the right side of the heel is an incorrect action.

The nurse is caring for an infant who has undergone a circumcision. The infant weighs 3 kg. What is the maximum daily dose of oral liquid acetaminophen (Tylenol) that can be administered to the infant? Record your answer using a whole number.

225 mg/day. The maximum dose of oral liquid acetaminophen (Tylenol) administered per day in an infant is 75 mg/kg/day. When an infant weighs 3 kg, the nurse can administer a maximum dose of (75 mg * 3 kg), which is 225 mg/day.

The nurse is assessing a newborn after 1 hour of delivery and finds that the newborn has chlamydia conjunctivitis. What prescription does the nurse expect from the primary health care provider? 1 A 14-day course of oral sulfonamide 2 A 28-day course of oral erythromycin 3 A 28-day course of topical tetracycline 4 A 14-day course of topical silver nitrate

A 14-day course of oral sulfonamide A 14-day course of oral sulfonamide is prescribed for chlamydia conjunctivitis. Apart from sulfonamide, oral erythromycin is also prescribed to treat chlamydia conjunctivitis, but only for a 14-day course. A 28-day course will increase the adverse effects in the newborn. Topical tetracycline and topical silver nitrate are ineffective in the treatment of chlamydia conjunctivitis.

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition? 1 A body weight of 7 pounds 2 A heart rate 120 beats/min 3 A head-to-heel length of 55 cm 4 A head circumference greater than chest circumference

A head circumference greater than chest circumference Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4.5 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/min indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.

On a winter morning the nurse finds the skin color of the newborn turning blue. The baby also has difficulty breathing. What should be the immediate nursing interventions to restore a normal condition in the baby? Select all that apply. 1 Administer glucose to the newborn. 2 Administer normal saline to the newborn. 3 Provide artificial ventilation to the newborn. 4 Set the incubator at a temperature above 22° C. 5 Administer vitamin K intramuscularly in the newborn.

Administer glucose to the newborn. Set the incubator at a temperature above 22° C. Set the incubator at a temperature above 22° C. The bluish skin color of the newborn is due to difficulty breathing, caused by cold stress. The cold stress increases the respiratory rate in the newborn, thereby depleting the glucose levels. Lack of oxygen causes the bluish tone of the skin. The nurse should administer glucose immediately to the newborn to restore the levels of glucose. Additionally, artificial ventilation is provided to restore the oxygen levels within the baby. The baby should be transferred to an incubator, which is maintained at a temperature of 22° to 26° C, because this helps combat the cold stress. Administration of normal saline cannot restore the glucose levels or promote oxygenation. Vitamin K is generally administered to all newborns to prevent bleeding, but it will not restore the glucose in the newborn or help with thermoregulation.

The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse? 1 Wrap the neonate in a warm blanket. 2 Administer vitamin K intramuscularly. 3 Provide ventilator support to the neonate. 4 Clean the neonate skin with lukewarm water.

Administer vitamin K intramuscularly. Petechiae rashes observed on a neonate indicate that the neonate has a defect related to clotting factors. Based on this finding the nurse would expect the primary health care provider to order the administration of vitamin K to improve clotting formation. Ventilator support is given when the fetal heart rate (FHR) is noted to be less than 100 beats/min. A neonate is kept in a warm blanket along with the mother to maintain thermoregulation. Cleaning the skin of a neonate does not wipe away petechiae rashes; instead, cleaning is done to remove the bloodstains after birth.

An infant born to a diabetic patient is prescribed oral glucose for the treatment of hypoglycemia. On assessment the nurse finds that the infant's cardiorespiratory condition is stable. Which is a priority nursing intervention in this case? 1 Lowering the dosage of oral glucose 2 Asking the parent to breastfeed 3 Initiating dextrose infusion 4 Obtaining blood from the heel for testing

Asking the parent to breastfeed The administration of oral glucose may trigger a massive insulin release and cause rebound hypoglycemia in the infant. Therefore the nurse instructs the parent to breastfeed if the infant's cardiorespiratory condition is stable. The nurse does not lower the dosage of oral glucose because a lower dosage may not have therapeutic effects. Dextrose infusion is necessary for infants born to women with poorly controlled diabetes. The aim is to maintain serum blood glucose levels between 40 and 50 mg/dL. Blood is obtained from the infant's heel for testing purposes to detect hypoglycemia in the infant, not after hypoglycemia is identified.

What type of bottle should the nurse advise the patient to purchase for the baby? 1 Clear plastic bottles 2 PC-printed clear bottles 3 Bisphenol A-free bottles 4 Recycling number 7 bottles

Bisphenol A-free bottles The nurse should instruct the patient to buy feeding bottles that are free of bisphenol A because it can cause life-threatening complications in the baby. The use of clear plastic bottles that are imprinted with recycling number 7 or PC-printed bottles must be avoided because they contain bisphenol A.

While assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? 1 Heart rate of 120 beats/min 2 Body temperature of 99.5° F 3 Blood glucose level of 38 mg/dL 4 Blood pressure (BP) of 80/40 mm Hg

Blood glucose level of 38 mg/dL Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dL of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dL (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120 beats/min, and BP of 80/40 mm Hg are normal values for a newborn and are not associated with the infant's manifestations.

Which condition may be seen in an infant born to a patient who consumed excessive alcohol during pregnancy? 1 Respiratory distress 2 Hypothyroidism 3 Congenital abnormalities 4 Skull fractures

Congenital abnormalities Infants born to mothers who are heavy alcohol drinkers are at risk for congenital abnormalities. Respiratory distress is not usually seen in an infant exposed to alcohol. Hypothyroidism is a genetic disorder not related to alcohol consumption. Skull fractures are sometimes caused during a difficult birth as a result of the pressure of the fetal skull against the maternal pelvis.

The nurse finds poor feeding, lethargy, and constipation in an infant. In reviewing the maternal history, the nurse finds that the infant's mother was treated for Graves' disease during pregnancy. Which condition does the nurse suspect in the infant? 1 Facial paralysis 2 Congenital hypothyroidism 3 Cytomegalovirus infection 4 Neonatal syphilis lesions

Congenital hypothyroidism A pregnant patient with Graves' disease is treated with antithyroid drugs, which may cause congenital hypothyroidism in the infant due to thyroid dysgenesis. Facial paralysis is a birth trauma seen in an infant as a result of a difficult birth. Cytomegalovirus infection is a rash on the infant's body caused by fetal exposure to drugs. Neonatal syphilis lesions are seen in an infant born to a mother with secondary syphilis.

The nurse is providing care for a pregnant patient who is expected to deliver in a week. The nurse finds that the patient is currently taking an antibiotic for a urinary tract infection caused by Escherichia coli. Which condition after birth is likely to be seen in the infant? 1 Hemolytic disease 2 Macrosomia 3 Hypoglycemia 4 Congenital sepsis

Congenital sepsis Congenital sepsis occurs in an infant as a result of direct contact with organisms from the maternal gastrointestinal and genitourinary tracts. Hemolytic disease refers to the destruction of red blood cells; it is not related to bacterial infection. Macrosomia refers to the condition of excessive weight gain in the infant as a result of the deposition of fat. Hypoglycemia is seen in an infant of a diabetic parent because of excessive insulin.

A patient reports to the nurse that the infant's face has a bluish hue. During what child behavior will the nurse expect the child to develop a darker hue? 1 Crying 2 Feeding 3 Laughing 4 Shivering

Crying Crying temporarily reverses the blood flow through the foramen ovale, a shunt that allows blood to enter the left atrium from the right atrium, which results in a darker skin tone due to a decrease in the infant's oxygen supply. While laughing, the infant may develop a pinkish tint on the face, but not a bluish hue. Shivering may cause hypothermia, but it, too, does not cause a bluish hue on the infant's face. Feeding does not influence the skin tone of the infant; it maintains regular blood flow and does not lead to decreased oxygen supply.

The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day. 2 Cut the nails while the baby is playing. 3 Cut the nails while the baby is sleeping. 4 Cut the nails while breastfeeding the baby. 5 Cover the baby's hands with loose-fitting mitts.

Cut the nails while the baby is sleeping. Cover the baby's hands with loose-fitting mitts. The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.

Newborns whose mothers are substance abusers frequently exhibit which behaviors? 1 Hypothermia, decreased muscle tone, and weak sucking reflex 2 Excessive sleep, weak cry, and diminished grasp reflex 3 Circumoral cyanosis, hyperactive Babinski reflex, and constipation 4 Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. They will have an uncoordinated sucking and swallowing reflex and hyperactive muscle tone. They will have poor sleeping patterns, increased reflexes, and a high-pitched cry. They will have diarrhea, not constipation.

While caring for an infant, which method should the nurse adapt to prevent heat loss due to evaporation? 1 Wrap the infant in a cloth. 2 Place the infant in a warm crib. 3 Place the crib away from the windows. 4 Dry the infant immediately after the bath.

Dry the infant immediately after the bath. The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.

Which action should the nurse perform before the infant is breastfed for the first time after birth? 1 Weigh the infant for documentation. 2 Provide eye prophylaxis to the infant. 3 Inject the infant with a vitamin K supplement. 4 Ensure skin-to-skin contact between the mother and infant.

Ensure skin-to-skin contact between the mother and infant. Skin-to-skin contact of an infant with the mother is associated with an increased rate and duration of breastfeeding. Therefore the nurse should ensure that skin-to-skin contact is maintained between the infant and mother. Other actions such as weighing the infant for documentation, providing eye prophylaxis, and injecting vitamin K should be delayed until the infant is breastfed for the first time.

The medical history of a patient who has just delivered an infant indicates drug abuse in the last few weeks of pregnancy. The newborn shows no signs of withdrawal symptoms in the first week after birth, and therefore the infant and the mother are discharged. Which nursing intervention is important in this case? 1 Establishing rapport and maintaining contact with the family 2 Instilling antibiotics in the infant's eyes before discharge 3 Referring the parent to a drug rehabilitation program 4 Asking the parent to avoid breastfeeding for a month

Establishing rapport and maintaining contact with the family If the parent uses drugs in the last weeks of pregnancy, it may take time for the withdrawal symptoms to appear in the child. The infant may have withdrawal symptoms after discharge, so the nurse needs to establish rapport and maintain contact with the family so that the family returns for treatment. Antibiotics are administered 1 hour after the infant is born to prevent infection. Referring the parent to a drug rehabilitation program is secondary in this case; it is more important to assess the infant's well-being. The nurse encourages breastfeeding as soon as the child is born if the mother is not using any illicit substances.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? The neonate: 1 Has hypothermia. 2 Exhibits normal findings. 3 Had stress during birth. 4 Has an infected umbilicus.

Exhibits normal findings.

Which infants are classified as being high risk? Select all that apply. 1 Extremely low-birth-weight (ELBW) infants 2 Intrauterine growth restriction (IUGR) infants 3 Small-for-gestational-age (SGA) infants 4 Appropriate-for-gestational-age (AGA) infants 5 Postterm (postmature) infants

Extremely low-birth-weight (ELBW) infants Intrauterine growth restriction (IUGR) infants Small-for-gestational-age (SGA) infants Postterm (postmature) infants ELBW infants have a birth weight less than 1000 g. They are susceptible to infections, environmental stress, and respiratory diseases. IUGR is a term for infants who have restricted intrauterine growth. The lack of maturity seen in these infants compromises their immune system. The birth weight of SGA infants falls below the 10th percentile on intrauterine growth curves. It makes these infants susceptible to respiratory disorders and other diseases. A postterm infant is born at 42 weeks' gestation, which extends beyond the full-term pregnancy. The infant may sometimes have progressive placental dysfunction. AGA infants are not high risk infants because their weights fall between the 10th and 90th percentiles on intrauterine growth curves.

The nurse examines a 6-day-old newborn and observes that the infant's skin color and sclera appear yellowish. What would the nurse expect to find in the laboratory reports of the infant? 1 Platelet count <150,000/mm3 2 Blood glucose levels <40 mg/dL 3 Free bilirubin levels >20 mg/dL 4 Leukocyte count <12,000/ mm3

Free bilirubin levels >20 mg/dL The infant's skin color and sclera of eyes appear yellow due to jaundice, which is caused by elevated unconjugated (free) bilirubin levels in the serum that is greater than 20 mg/dL (hyperbilirubinemia). Yellowing of the skin, or jaundice, is not caused by abnormal levels of platelets, blood glucose levels, or leukocytes. A platelet count of less than 150,000/mm3 indicates vitamin K deficiency, which can lead to severe hemorrhage. Blood glucose levels that are less than 40 mg/dL indicates hypoglycemia, and a leukocyte count of less than 12,000/mm3 indicates that the newborn has sepsis.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min

Heart rate of 70 beats/min The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.

Upon assessing a newborn, the nurse finds that the baby has swelling in the breast and thin milky discharge from the nipples. What does the nurse expect to be the reason for this finding? 1 Low levels of bilirubin during pregnancy 2 High levels of estrogen during pregnancy 3 Low levels of progesterone during pregnancy 4 High levels of catecholamines during pregnancy

High levels of estrogen during pregnancy Some infants have a swelling in the breast with a thin milky discharge from the nipples due to high estrogen levels during pregnancy (hyperestrogenism of pregnancy). It has no critical significance and no treatment is required. During pregnancy, estrogen and progesterone levels are always elevated. Low bilirubin levels indicate that the infant will not have jaundice after birth. However, high progesterone does not cause jaundice. Low levels, not high levels, of catecholamines during pregnancy lead to transient tachypnea of the newborn (TTNB).

Which conditions is the nurse alert for in a preterm infant with respiratory distress syndrome? Select all that apply. 1 Hypoxemia 2 Metabolic acidosis 3 Pulmonary hemorrhage 4 Mucus plugging 5 Jaundice

Hypoxemia Metabolic acidosis Inadequate pulmonary perfusion and ventilation produce hypoxemia and hypercapnia in the preterm infant. Prolonged hypoxemia increases the amounts of lactic acid and results in metabolic acidosis. Pulmonary hemorrhage and mucus plugging are side effects of surfactant therapy used in an infant with respiratory distress syndrome. Jaundice is not caused by respiratory distress syndrome. It occurs because of an increase in bilirubin levels in the blood.

After assessing an infant's health screening reports, the nurse instructs the mother to stop breastfeeding and switch to a soy-based formula. What findings most likely caused the nurse to recommend this change? 1 Elevated leucine levels in the infant 2 Increased galactose levels in the infant 3 Elevated methionine levels in the infant 4 Increased thyrotropin levels in the infant

Increased galactose levels in the infant Galactosemia is a condition where the galactose levels are elevated in an infant. If this condition is present, the nurse would instruct the mother to stop breastfeeding, because breast milk is contraindicated in infants with galactosemia. Elevated leucine causes maple syrup urine disease in an infant but is not a contraindication for breastfeeding. Elevated methionine causes homocystinuria in infants who are supplemented with thiamine. Elevated thyrotropin, or elevated thyroid-stimulating hormone (TSH), causes congenital hypothyroidism in infants. The parents of infants suffering from congenital hypothyroidism are instructed to get the newborn's bone mass tested regularly.

Which therapy is the primary health care provider likely to prescribe for a late-preterm infant with persistent pulmonary hypertension? 1 Inhaled nitric oxide 2 Fluid therapy 3 Skin-to-skin contact 4 Phototherapy

Inhaled nitric oxide Inhaled nitric oxide is blended with oxygen and administered through the ventilator circuit for the treatment of persistent pulmonary hypertension in late-preterm infants. Fluid therapy is more effective in infants with fluid imbalances, not pulmonary hypertension. Skin-to-skin contact is used to help infants maintain thermal stability. Phototherapy is an effective treatment for infants with jaundice because it helps decrease bilirubin levels.

The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant? 1 Intravenous (I.V.) hepatitis B vaccine 2 Intramuscular (IM) hepatitis B vaccine 3 Intravenous (I.V.) hepatitis B immune globulin (HBIG) 4 Intramuscular (IM) hepatitis B immune globulin (HBIG)

Intramuscular (IM) hepatitis B immune globulin (HBIG) A dose of IM HBIG should be given to the infant whose mother's hepatitis B surface antigen's (HBsAg) status is determined to be positive. The vaccine is also given to infants who weigh 2000 g or more before 1 week of age. The hepatitis B vaccine and HBIG are not given through the IV route in infants because of their adverse effects. The IM hepatitis B vaccine is given to infants born to hepatitis B surface antigen (HBsAg)-negative mothers before being discharged from the hospital.

The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise? 1 Cow's milk orally 2 Infant formula orally 3 Intravenous (I.V.) saline infusion 4 Intravenous (I.V.) dextrose infusion

Intravenous (I.V.) dextrose infusion If the glucose levels are less than 25 mg/dL in the first 4 hours, or less than 35 mg/dL in the first 4 to 24 hours, it indicates hypoglycemia. All infants at risk for hypoglycemia should be fed within the first hour, with glucose testing performed 30 minutes after breastfeeding. If the glucose levels remain low despite feeding, I.V. dextrose is prescribed to the newborn. Cow's milk is generally not preferred for infants, because it may cause infections. Administration of infant formula is recommended in infants with hypocalcemia. I.V. saline infusion is not beneficial to hypoglycemic infants, because a saline infusion consists of plain salts and does not increase the glucose levels in the body.

A patient tells the nurse she is concerned that her newborn responds to the ringing of a rattle for the first three times but does not respond to the ringing of the rattle after that. What could be the reason for the infant's behavior? The child: 1 Has a hearing impairment. 2 Is habituated to the sound. 3 Cannot tolerate the sound. 4 Has cerebral disorientation.

Is habituated to the sound. Habituation is a protective mechanism in infants. This helps the infant get accustomed to various stimuli in the extrauterine environment. The response decreases as the infant is repetitively exposed to the same stimulus. Because the infant responded to the first three sounds of the rattle, it indicates that the infant does not have hearing impairment. If the infant cannot tolerate the sound, the infant will start crying to the sound of the rattle. If the infant has cerebral disorientation, he or she might not respond to the first three sounds of the rattle.

It is routine for all newborns to receive at least two intramuscular injections before discharge. A single dose of vitamin K is administered shortly after birth. Hepatitis B vaccine is given before discharge. You are about to administer the hepatitis vaccine. On the leg, click on the acceptable intramuscular site for the newborn infant.

It is important that the nurse select the appropriate equipment and site for intramuscular injections. In most cases a 25-gauge, 5/8-inch needle is used. Injections must be given in sites that are large enough to accommodate the medication and avoid major nerves and blood vessels. The vastus lateralis is the preferred injection site for all newborns. The dorsogluteal muscle in newborns is very small, poorly developed, and too close to the sciatic nerve to be an ideal injection site.

The nurse is caring for a two-day-old term infant who was circumcised six hours ago. He is restless and fussy and refuses to breastfeed. The nurse attempts non-pharmacologic interventions with minimal results. What medication does the nurse expect the primary health care provider to order as an analgesic for the newborn? 1 Oral sucrose 2 Liquid acetaminophen 3 Topical prilocaine-lidocaine (EMLA) 4 Intravenous (I.V.) fentanyl

Liquid acetaminophen Oral liquid acetaminophen is a nonopioid analgesic that may be used to reduce pain following circumcision. It may be administered every 4 hours, not to exceed 75 mg/kg/day. Oral sucrose may be given before circumcision along with 4% lidocaine as a topical anesthetic; it is not used to alleviate postcircumcision pain. Prilocaine-lidocaine (EMLA) is a local anesthetic applied topically prior to circumcision. Bolus or continuous IV infusion of opioids, like fentanyl provide effective pain control with low incidence of adverse effects; however, these are most often used for more severe pain.

Upon assessing the laboratory reports of an infant, the nurse finds an abnormality in the infant's bone development. The nurse instructs the parents to perform periodic checkups and monitor the growth of the infant. What did the nurse find in the infant's laboratory reports? 1 Decreased galactose levels 2 Low methionine levels 3 Decreased phenylalanine levels 4 Low thyroxine (T4) levels

Low thyroxine (T4) levels Low T4 levels may retard the growth of the infant. Therefore it is important to monitor the regular growth of the infant, particularly pertaining to bone growth. Low levels of galactose may affect the immune system in the body, making it nonfunctional. Low methionine levels may cause liver damage. Low phenylalanine levels lead to intellectual disability in infants. However, low levels of galactose, methionine, and phenylalanine do not affect the bone growth of the child. Therefore it is not suggested to monitor the bone growth if any of these chemical molecules decreases in the infant.

The nurse is assessing a neonate who has undergone phototherapy. The nurse finds the transcutaneous bilirubinometry (TcB) reading to be 13 mg/dL. What should the nurse infer about the neonate from these findings? The neonate: 1 Has not been breastfed. 2 May require blood transfusion. 3 Needs to receive oral acetaminophen (Tylenol). 4 Requires intravenous dextrose infusion.

May require blood transfusion. A transcutaneous bilirubinometry (TcB) reading greater than 12 mg/dL indicates excessive serum unconjugated bilirubin levels. If these levels persist even after the phototherapy, the neonate may require blood transfusion to decrease the serum unconjugated bilirubin levels. Breastfeeding the neonate increases the gastric motility and eliminates excess bilirubin. Therefore breastfeeding is encouraged during hyperbilirubinemia. Oral acetaminophen (Tylenol) is given to alleviate the pain in a neonate associated with procedures such as circumcision. Dextrose infusion is administered when a neonate has low glucose levels.

The nurse observes fever, diarrhea, and vomiting in an infant 2 days after birth. On assessment the nurse finds that the mother used drugs during pregnancy. Which is the best screening method to determine the cause of the infant's condition? 1 Coombs' test 2 Kleihauer-Betke assay 3 Meconium sampling 4 Urine toxicology

Meconium sampling An infant born to a parent who uses drugs is likely to have the withdrawal effects of the drug. Therefore meconium sampling is performed because it helps identify drug exposure. Coombs' test is used to identify antibodies in the blood. The Kleihauer-Betke assay is used to assess transplacental bleeding. Urine toxicology may be used to assess drug exposure, but it may provide less accurate results because it reflects only recent substance intake by the mother.

Which action does the nurse implement in the plan of care of a breastfeeding infant if the mother is taking selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression? 1 Monitors the infant for sleep disturbances 2 Administers antibiotics to the infant 3 Assesses the infant's skin for side effects 4 Asks the parent to avoid breastfeeding

Monitors the infant for sleep disturbances SSRIs are prescribed for depression. However, the drugs pass into the breast milk after the infant's birth and cause sleep disturbances, irritability, and poor feeding. Hence, the nurse needs to monitor the infant for these conditions. The nurse administers antibiotics to infants who have infections. SSRIs do not have any side effects on the infant's skin. The nurse does not ask the parent to avoid breastfeeding because breast milk is beneficial for the infant's health.

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: 1 tonic neck reflex. 2 Moro reflex. 3 cremasteric reflex. 4 Babinski reflex.

Moro reflex. These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

The nurse is caring for an infant with candidiasis. Despite being treated with topical clotrimazole (Pedesil), the infection persists. Which medication does the primary health care provider prescribe? 1 Oral fentanyl (Sublimaze) 2 Oral nystatin (Mycostatin) 3 Topical miconazole (Desenex) 4 Morphine infusion (Duramorph)

Oral nystatin (Mycostatin) Persistence of the candidiasis even after antifungal therapy indicates any gastrointestinal source of infection. To eliminate any gastrointestinal source of candidiasis, oral nystatin (Mycostatin) is prescribed. Oral fentanyl (Sublimaze) is an analgesic and does not combat the infection in the body. Topical miconazole (Desenex) is of no use in this condition, because the infection is internal and it is used to treat fungal infections on the skin. Intravenous (I.V.) morphine infusion (Duramorph) is an analgesic. It is not used to treat candidiasis.

The nurse is caring for an infant who cries in a high-pitched voice. When the crying ceases, the nurse wants to check the blood pressure (BP) of the newborn. What device does the nurse most preferably use? 1 Oscillometric monitor 2 Aneroid sphygmomanometer 3 Mercury sphygmomanometer 4 Ultrasonic Doppler flow meter

Oscillometric monitor An oscillometric monitor is a device used to check the BP in neonates. It is an easy-to-operate digital monitor and does not cause any pain to the infants while it is being used. Aneroid sphygmomanometers and mercury sphygmomanometers are the manual sphygmomanometers and are difficult to use for checking the BP of infants. An ultrasonic Doppler flow meter is the device used for evaluating the hemodynamics of the vascular system (blood flow).

The nurse advises the postpartum patient to breastfeed regularly to lower her risk for postpartum hemorrhage. What is the reason behind this suggestion? This method of feeding increases: 1 Lactose production. 2 Oxytocin production. 3 Estrogen production. 4 Progesterone production.

Oxytocin production. Breast milk production follows the supply-meets-demand system. The more the patient breastfeeds the infant, the greater the demand for production. This, in turn, increases the production of oxytocin. Oxytocin is the hormone that helps in uterine contraction and involution and decreases the risk of postpartum hemorrhage. Other hormones are present at the appropriate levels but are not related to postpartum hemorrhage.

The nurse finds that a pregnant patient is Rh negative and the fetus is Rh positive. Which event would pose a potential risk to the fetus? 1 Placental separation 2 Blood transfusion 3 Cesarean birth 4 Fluid imbalance

Placental separation Placental separation increases the risk of fetal blood being transferred to the maternal circulation. This may result in maternal antibody production, which may attack and destroy fetal erythrocytes. Blood transfusions help improve the condition of the affected fetus. Caesarean birth does not cause a hemolytic reaction in the newborn. Fluid imbalance does not present a risk to the Rh-negative mother and Rh-positive fetus. It can be treated with appropriate fluid replacement therapy.

Which condition in a preterm infant in the neonatal period can increase the risk for respiratory distress? 1 Galactosemia 2 Fluid imbalance 3 Pneumonia 4 Jaundice

Pneumonia Pneumonia in a preterm infant causes respiratory distress due to bacterial or viral agents. Galactosemia is an autosomal recessive disorder that indicates a deficiency of galactose 1-phosphate uridyltransferase (GALT) and causes hepatic dysfunction. As a result the infant is more susceptible to jaundice, not respiratory distress. Fluid imbalance does not cause respiratory distress; it may cause dehydration in an infant. Jaundice is caused by an increase in bilirubin levels due to a hemolytic disease. It does not increase the risk for respiratory distress.

The nurse assesses the circumcision site of an infant every 20 minutes for the first hour to check for bleeding. The nurse identifies uncontrollable bleeding at the site. What is the most important nursing intervention? 1 Prepare for blood vessel ligation. 2 Clean the bleeding site continuously. 3 Administer an analgesic to reduce the pain. 4 Apply strong pressure to stop the bleeding.

Prepare for blood vessel ligation. If the bleeding from the circumcision site is not easily controlled, then the blood vessel may need to be ligated. In this event, the nurse will notify the primary health care provider (PHP). Cleaning the bleeding site continuously is recommended to avoid infection. However, it does not reduce bleeding from the circumcision site. Administering an analgesic reduces the pain at the site of the circumcision but does not reduce the loss of blood from the site. The nurse applies gentle pressure with a folded sterile gauze pad. The nurse should not apply strong pressure on the site, because it increases the pain.

The primary health care provider instructs the patient not to alter the concentration of formula while feeding her infant. What could happen to the infant if the formula is concentrated? 1 The kidneys would become functional. 2 Growth would be abnormally increased. 3 Bilirubin levels would become excessive. 4 Proteins in the formula would exceed the infant's excretory ability.

Proteins in the formula would exceed the infant's excretory ability. An infant's kidneys are too immature to excrete large protein molecules. Concentrated formula may contain large protein molecules that may not be excreted and may impair kidney function. Concentrated formula does not increase growth; in fact, it may stall growth because the infant may not be able to digest it. Bilirubin levels are not affected by the concentration of the infant's formula.

The nurse reports a neonate's heart rate as 9 beats in 6 seconds. What does the nurse expect the primary health care provider (PHP) to advise in order to restore the normal heart rate? 1 Administer epinephrine. 2 Administer normal saline. 3 Provide ventilation support. 4 Provide chest compressions.

Provide ventilation support. The heart rate reported as 9 beats in 6 seconds can be taken as 90 beats/min. When the heart rate is below 100 beats/min, the PHP would instruct the nurse to give ventilation support to the infant. Intravenous (I.V.) epinephrine is administered when the heart rate is still below 60 beats/min, even after providing chest compressions. Infusing normal saline is not indicated for a heart rate of 90 beats/min. Therefore the PHP prescribes chest compressions if the heart rate is less than 60 beats/min but not less than 90 beats/min.

The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate? 1 Provide warmth to the neonate. 2 Provide ventilator support to the neonate. 3 Provide chest compressions to the neonate. 4 Clean the neonate's body with lukewarm water.

Provide warmth to the neonate. The neonate born on the way to hospital may become hypothermic, so the nurse should gradually warm the neonate's body to avoid apneic spells (insufficiency breathing). Rapid warming may cause apneic spells. Thus the warming process should be gradual. Ventilator or chest compressions are given when a neonate already has respiratory distress, which is identified by assessing the heart rate. The nurse can use lukewarm water to clear the stains on the neonate's body only after thermal stability is achieved.

The nurse is caring for a 3-week-old infant. Upon assessment, the nurse finds that the infant has impaired acoustic nerve functioning. What does the nurse infer from this finding about the infant's clinical condition? The infant has: 1 Cataracts in the eye. 2 Regular laryngospasms. 3 Reduced hearing abilities. 4 Persisting petechiae on the skin.

Reduced hearing abilities. The hearing function of an infant is assessed by examining acoustic nerve stimulations. This can be performed with the evoked otoacoustic emissions (EOAE) test and auditory brainstem response (ABR) test. Cataracts are usually observed in an infant with elevated galactose levels. Impaired acoustic nerve stimulation does not indicate laryngospasms. Laryngospasms in an infant signifies lowered calcium levels. Persisting petechiae indicate an underlying hemorrhage disorder in an infant and are not related to the acoustic nerve stimulations.

The nurse is caring for an infant born at 28 weeks of gestation. Which complication can the nurse expect to observe during the course of the infant's hospitalization? Select all that apply. 1 Polycythemia 2 Respiratory distress syndrome 3 Meconium aspiration syndrome 4 Periventricular hemorrhage 5 Persistent pulmonary hypertension 6 Patent ductus arteriosus

Respiratory distress syndrome Periventricular hemorrhage Patent ductus arteriosus Respiratory distress syndrome, periventricular hemorrhage, and a patent ductus arteriosus are common complications with preterm infants. Polycythemia, meconium aspiration syndrome, and persistent pulmonary hypertension are complications of postmaturity.

The nurse is planning the diet plan for a Korean postpartum patient. What food should the nurse include in the patient's diet plan to increase the production of breast milk? 1 Clarified butter 2 Corn syrup 3 Boiled chicken 4 Seaweed soup

Seaweed soup Seaweed soup is preferred by Korean patients after delivery to increase milk production. Some cultures believe that clarified butter will clear out meconium. Corn syrup solids are added to infant formula to increase carbohydrate levels. Hmong patients prefer boiled chicken as the part of their diet in the first month after birth.

The nurse is assessing a newborn undergoing phototherapy. What changes would the nurse likely notice in the newborn during the process? Increased: 1 Urinary output 2 Stool frequency 3 Skin discoloration 4 Blood pressure

Stool frequency Phototherapy is performed in the newborn with increased bilirubin levels (jaundice). During this process excess bilirubin is eliminated through stools and increases the gastric motility. Therefore the nurse may observe an increase in stool frequency in a newborn. Urinary output may be reduced or may remain unaltered as a result of hydration, but it does not increase during the phototherapy session. An increase in blood pressure in the newborn is a rare observation and is not associated with phototherapy. During phototherapy the yellow discoloration of the skin caused by jaundice is reduced, not increased.

While assessing breastfeeding in a postpartum patient, the nurse finds that the baby does not feed properly even when hungry. What is the best nursing intervention? 1 Teaching about effective latching of the baby onto the breast 2 Advising the patient to feed the baby from a bottle 3 Teaching the patient to feed the baby in the hunched position 4 Advising the patient to continue breastfeeding the same way

Teaching about effective latching of the baby onto the breast Latching is the sufficient grip of the infant's mouth over the mother's breast for effective breastfeeding. If the baby is hungry even after breastfeeding, it implies that the baby is not latching properly, resulting in inadequate feeding. Therefore the nurse should help the baby latch properly. Bottle-feeding is not advised until breastfeeding has been well established. Feeding in the hunched position would not help in latching, resulting in inadequate feeding of the infant. If the patient continues breastfeeding in the same way, the baby may remain hungry and may not be well fed.

Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this? 1 The infant wakes up frequently. 2 The infant's skin has a pink complexion. 3 The infant requires 40% oxygen support. 4 The infant's Heart rate was 110 beats/min.

The infant requires 40% oxygen support. According to the CRIES scale, the infant is experiencing severe pain when he or she requires more than 30% oxygen support to maintain normal functioning. The normal heart rate of an infant is 110 beats/min. The heart rate increases when the infant cries. A pink complexion is a normal indication, so a pink complexion does not cause the nurse to conclude that the infant is in severe pain.

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature? 1 The mother has undergone cesarean birth. 2 The mother has gestational hyperglycemia. 3 The mother has been administered magnesium sulfate. 4 The mother has received Ringer's lactate solution.

The mother has been administered magnesium sulfate.

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition? 1 Urinary output 2 Barrel-shaped chest 3 Webbing around the neck 4 Pinkish coloration of the skin

Urinary output The nurse should check the newborn's urinary output to validate Potter syndrome, because a newborn with this condition does not void in the first 24 hours after birth. Therefore Potter syndrome will reduce the urinary output of the neonate. A barrel-shaped chest is a common finding in any newborn. Webbing around the neck region of the neonate is a primary symptom of Turner syndrome, but it is not associated with Potter syndrome. Pinkish coloration of the skin is a normal finding of any healthy neonate and is not associated with Potter syndrome.

Which statement provides helpful and accurate nursing advice concerning bathing the newborn? Select all that apply. 1 Newborns should be bathed every day, for the bonding as well as the cleaning. 2 Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. 3 Only plain warm water can be used to preserve the skin's acid mantle. 4 Powders are not recommended because the infant can inhale powder. 5 Bathe immediately after feeding while baby is calm and relaxed.

Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Powders are not recommended because the infant can inhale powder. Tub baths may be given as soon as an infant's temperature has stabilized. Powder is not recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.

The nurse is teaching a new mother about breastfeeding. What infant assessment should the nurse ask the mother to assess to find out whether the infant's milk intake is adequate? 1 Urine output 2 Sleeping cycles 3 Growth pattern 4 Frequency of crying

Urine output The infant's urine output is directly related to milk intake. Therefore, if breastfeeding is adequate, the infant's urine frequency will increase. In addition, urine is less concentrated and light yellow in color. Sleeping cycles in infants are unrelated to feeding. Long-term growth patterns may be related to the nutritional composition of the milk but may not be related to the quantity of milk intake. Not all infants cry for hunger.

Which intervention does the nurse include while providing care for a high risk infant who is receiving supplemental parenteral fluids? 1 Uses continuous infusion pumps and monitors hourly 2 Administers a one-time bolus infusion of 10% dextrose 3 Avoids phototherapy sessions when administering fluids 4 Uses the median cubital vein to administer medications

Uses continuous infusion pumps and monitors hourly The nurse uses continuous infusion pumps that deliver fluids at a preset flow rate. The nurse also monitors the infusion hourly to prevent tissue damage from extravasation, fluid overload, or dehydration. A high risk infant may not be able to tolerate dextrose and may be at risk for glycosuria and osmotic diuresis. Infants receiving phototherapy have increased water loss. Therefore fluids are adjusted according to their needs. The peripheral veins, scalp veins, and antecubital veins, not the median cubital vein, are used to administer fluids intravenously.

The nurse assesses a postpartum patient who is breastfeeding her infant. The patient states that she does not consume eggs or meat. Which deficiency does the nurse expect the infant to have? 1 Vitamin D deficiency 2 Vitamin E deficiency 3 Vitamin K deficiency 4 Vitamin B12 deficiency

Vitamin B12 deficiency The patient does not consume eggs and meat, which are rich sources of vitamin B12. Therefore the infant should receive supplemental vitamin B12 from birth to decrease the risk associated with vitamin B12 deficiency. Vitamin D is absent in human milk. It is produced in infants when they are exposed to sunlight. Vitamin E deficiency is not observed in patients who do not consume eggs and meat. Deficiency of vitamin K may occur in the infant if the patient does not consume green leafy vegetables.

Which infant has a higher possibility of sustaining a birth trauma? An infant who: 1 Was delivered by a vaginal birth 2 Has low glucose levels at birth 3 Has inborn errors of metabolism 4 Was born to a patient with a urinary tract infection

Was delivered by a vaginal birth A vaginal birth increases the chance of injuries because of the use of forceps or vacuum extraction or because of pressure of the fetal skull against the maternal pelvis. An infant with low glucose levels at birth is hypoglycemic. Inborn errors of metabolism refer to an inherited disease and are not a birth trauma. An infant born to a patient with a urinary tract infection has a higher chance of acquiring the infection, but this is not a birth trauma.

The nurse is assessing an infant born after 42 weeks' gestation. Which characteristics may be seen in the infant? Select all that apply. 1 Weak gag reflex 2 Wasted physical appearance 3 Green vernix caseosa 4 Small, scrawny appearance 5 Soft cranium

Wasted physical appearance Green vernix caseosa An infant born after 42 weeks' gestation is a postterm infant. The infant may have a wasted physical appearance that indicates intrauterine deprivation. There is little green or deep yellow vernix caseosa in the infant's skinfolds, which indicates meconium in the amniotic fluid. Weak gag reflex, small and scrawny appearance, and a soft cranium are characteristics of a preterm infant.

The nurse is assessing a neonate who is administered vitamin K intramuscularly (IM). What changes in the neonate would the nurse primarily monitor to ensure safety? 1 Increased heart rate 2 Increased body moments 3 Pink coloration of the skin 4 Yellow discoloration of sclera

Yellow discoloration of sclera After vitamin K is administered, neonates develop jaundice-like side effect. Therefore the nurse should look for a yellow discoloration in neonates who have been administered vitamin K. Increased heart rate is a very rare complication observed in neonates. It is primarily observed when a neonate cries, but not when vitamin K is administered IM. Increased body movements may indicate Down syndrome and are not adverse effects of vitamin K. Pink coloration of the skin is a normal finding in neonates and is not associated with jaundice-like effects.

Concerning congenital abnormalities involving the central nervous system, nurses should be aware that: 1 although the death rate from most congenital anomalies has decreased over the past several decades, neural tube defects (NTDs) have gone up in the last few years. 2 spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present. 3 a major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. 4 microcephaly can be corrected with timely surgery.

a major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. The nurse protects the infant by laying the baby on his or her side. Most congenital anomalies have had a stable neonatal death rate since the 1930s; NTDs are declining because of mandatory food fortification with folic acid. Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac. Microcephaly is a tiny head; there is no treatment.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: 1 the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. 2 two thirds of newborns with fetal alcohol syndrome (FAS) are boys. 3 alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) often are not detected until the child goes to school. 4 both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) often are not detected until the child goes to school. Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: 1 instill within 15 minutes of birth for maximum effectiveness. 2 cleanse eyes from inner to outer canthus before administration. 3 apply directly over the cornea. 4 flush eyes 10 minutes after instillation to reduce irritation.

cleanse eyes from inner to outer canthus before administration. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment . Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.

Vitamin K is given to the newborn to: 1 reduce bilirubin levels. 2 increase the production of red blood cells. 3 enhance ability of blood to clot. 4 stimulate the formation of surfactant.

enhance ability of blood to clot. Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: 1 apply topical anesthetics with each diaper change. 2 expect a yellowish exudate to cover the glans after the first 24 hours. 3 change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. 4 apply constant pressure to the site if bleeding occurs and call the physician.

expect a yellowish exudate to cover the glans after the first 24 hours. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: 1 birth injury. 2 hypocalcemia. 3 hypoglycemia. 4 seizures.

hypoglycemia. This infant is macrosomic and at risk for hypoglycemia. The tremors are jitteriness that is associated with hypoglycemia. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: 1 decreased activity level. 2 increased respiratory rate. 3 hyperglycemia. 4 shivering.

increased respiratory rate. An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: 1 place the thermistor probe on the left side of the chest. 2 cover the probe with a nonreflective material. 3 recheck the temperature by periodically taking a rectal temperature. 4 prewarm the radiant heat warmer and place the undressed newborn under it.

prewarm the radiant heat warmer and place the undressed newborn under it. The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.

With regard to hemolytic diseases of the newborn, nurses should be aware that: 1 Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. 2 ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. 3 exchange transfusions frequently are required in the treatment of hemolytic disorders. 4 the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

With regard to umbilical cord care, nurses should be aware that: 1 the stump can easily become infected. 2 a nurse noting bleeding from the vessels of the cord should immediately call for assistance. 3 the cord clamp is removed at cord separation. 4 the average cord separation time is 5 to 7 days.

the stump can easily become infected. The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is: 1 tetralogy of Fallot. 2 ventriculoseptal defect (VSD). 3 pulmonary stenosis. 4 transposition of the great vessels.

ventriculoseptal defect (VSD). VSD with increased pulmonary blood flow is the most common type of heart defect with a prevalence of 27 per 10,000 births and accounts for about 30% to 35% of all congenital heart defects. Tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac defect with decreased blood flow. Pulmonary stenosis is less common and is a defect that causes obstruction to blood flow out of the heart. Transposition of the great vessels is a complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the heart or great vessels.

When weighing a newborn, the nurse should: 1 leave its diaper on for comfort. 2 place a sterile scale paper on the scale for infection control. 3 keep hand on the newborn's abdomen for safety. 4 weigh the newborn at the same time each day for accuracy.

weigh the newborn at the same time each day for accuracy. The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above (not on) the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.

On interacting with a lactating patient, the nurse finds that the patient consumes alcohol. Which advice should the nurse give in order to prevent potential risks to the infant? 1 "Avoid consuming grape juice while breastfeeding." 2 "Pump and discard the first 10 drops of breast milk." 3 "Avoid breastfeeding for 2 hours after consuming alcohol." 4 "Feed the infant cow's milk rather than breast milk."

"Avoid breastfeeding for 2 hours after consuming alcohol." If a breastfeeding mother consumes alcohol, she is advised to avoid breastfeeding for at least 2 hours after doing so. This will avoid potential risks to the infant. Consuming grape juice is beneficial during breastfeeding, but it does not reduce risks in the infant. Pumping and discarding the first 10 drops of milk is not sufficient to remove alcohol. Breast milk is nutritionally superior to cow's milk. Therefore the nurse should advise the patient to feed the infant breast milk rather than cow's milk.

What does the nurse instruct a postpartum patient to do before initiating breastfeeding? 1 "Spread a few drops of milk on the nipple." 2 "Insert only the nipple into the infant's mouth." 3 "First give milk in the feeding bottle to the infant." 4 "Do not give any additional support to your breasts."

"Spread a few drops of milk on the nipple." Spreading a few drops of expressed milk on the nipple facilitates lubrication and enables the baby to open his or her mouth easily. The nurse should instruct the patient to insert the nipple and areola of the breast into the baby's mouth. This practice ensures good latching and less pain and discomfort in the mother. The mother need not start giving bottle milk until breastfeeding is established. The breasts should be supported sufficiently to promote effective latching and positioning of the infant.

Which statement by the student nurse about a diabetic pregnancy and the fetal side effects indicate effective learning? 1 "The euglycemic status will influence fetal well-being." 2 "The infant will be born with congenital malformations." 3 "The infant is likely to have diabetes after birth." 4 "Hyperglycemia is the only reason for fetal macrosomia."

"The euglycemic status will influence fetal well-being." The euglycemic status will influence fetal well-being, because a decrease or increase in the blood glucose levels enhances the risks for complications in the fetus. Congenital malformations are more likely to be seen in infants exposed to alcohol, not as a result of diabetes. The infant is not likely to have diabetes after birth but may have hypoglycemia, because the infant's glucose supply is removed abruptly at the time of birth. Hyperglycemia is not the only reason for fetal macrosomia. Macrosomia is caused by maternal hyperlipidemia and increased lipid transfer to the fetus.

Which instruction about feeding does the nurse give to the parent of a low-birth-weight infant with septicemia? 1 "Don't breastfeed before administering the medications." 2 "You may breastfeed your infant every 3 hours." 3 "Use infant formulas for the first 2 weeks." 4 "You may choose not to breastfeed at all."

"You may breastfeed your infant every 3 hours." Breast milk contains iron-binding proteins that exert a bacteriostatic effect on Escherichia coli. Breast milk also serves as a barrier to infection because it contains macrophages and lymphocytes. The infant can be breastfed every 3 hours to ensure proper rest between the feeding intervals. It is not necessary to stop breastfeeding while administering medications because the medicines do not interact with breast milk. Infant formulas are not advised because they do not contain protective mechanisms against infection. The nurse should encourage the mother to breastfeed because it is beneficial for the infant.

A newborn infant is prescribed tandem mass spectrometry. The parents ask the nurse about the test. Which is the best response by the nurse? "The test will help: 1 Determine whether the infant is at risk for diabetes." 2 Assess inborn errors of metabolism in the infant." 3 Assess whether the child has any neurologic disorders." 4 Assess whether the infant was exposed to any drugs."

Assess inborn errors of metabolism in the infant." Tandem mass spectrometry helps detect more than 20 inborn errors of metabolism. Blood glucose tests are more effective in understanding the risk of diabetes in the infant. Electroencephalography and brain magnetic resonance imaging (MRI) are used to understand neurologic disorders. Meconium sampling helps assess whether the infant was exposed to any drugs during pregnancy.

Which statement indicates the effect of breastfeeding on the family or society at large? Select all that apply. 1 Breastfeeding requires fewer supplies and less cumbersome equipment. 2 Breastfeeding saves families money. 3 Breastfeeding costs employers in terms of time lost from work. 4 Breastfeeding benefits the environment. 5 Breastfeeding results in reduced annual health care costs..

Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding saves families money. Breastfeeding benefits the environment. Breastfeeding results in reduced annual health care costs.. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. Breastfeeding saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Less time is lost from work by breastfeeding mothers, in part because infants are healthier. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal. Breastfeeding results in reduced annual health care costs.

The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? The infant: 1 Did not cry after birth. 2 Had improper bowel sounds. 3 Moved its head from side to side. 4 Had increased blood pressure (BP).

Did not cry after birth. The nurse concludes that the newborn has difficulty breathing because the infant did not cry after birth. Crying creates positive intrathoracic pressure, which helps draw air into the alveoli of lungs and promotes respiration. Increased BP is a normal finding after the birth and does not cause any breathing difficulties. Improper bowel sounds may indicate a gastrointestinal disorder but are not related to respiration. Side to side head movement is common after the birth of an infant, and it is not associated with breathing difficulties.

A mother of a newborn reports to the nurse that the child developed bluish pigmentation on the back. What could be the reason for this condition? 1 Infection 2 Hypothermia 3 Polycythemia 4 Mongolian spots

Mongolian spots Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells (RBCs) on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn.

Which actions does the nurse take while counseling anxious parents who visit their preterm infant in an intensive neonatal care unit? Select all that apply. 1 Explains the function of each piece of equipment used 2 Avoids telling the parents any unpleasant facts 3 Informs the parents that they can visit anytime 4 Persuades the parents to touch and hold the infant 5 Encourages the parents to express their sadness

Explains the function of each piece of equipment used Informs the parents that they can visit anytime Encourages the parents to express their sadness The nurse explains the function of each piece of equipment that is attached to the infant because this helps lessen fears and anxiety in the parents. The nurse may further alleviate their anxiety by informing them that they can visit the infant anytime. The nurse encourages the parents to express feelings of sadness so that they are better able to focus on their infant. The nurse needs to inform the parents honestly about all of the infant's conditions. The parents may not be ready to touch or hold the infant because of fear. Therefore the nurse should not persuade the parents to do so and should let the parents adjust to the infant's condition.

The nurse is assessing a very low-birth-weight infant who had a preterm birth. Which condition is likely to be seen in the infant? 1 Facial nerve paralysis 2 Congenital sepsis 3 Ischemic injury 4 Macrosomia

Ischemic injury The increase or decrease in cerebral blood flow subsequent to asphyxia makes preterm infants vulnerable to ischemic injury. Facial nerve paralysis is a birth trauma resulting from a difficult birth. Congenital sepsis in the infant may be caused by a maternal urinary tract infection. Macrosomia is seen in infants born to diabetic mothers.

A preterm infant is receiving oxygen therapy for respiratory distress syndrome. Which are the important nursing interventions to be included in the plan of care? Select all that apply. 1 Monitoring continuously 2 Suctioning twice a day 3 Assessing skin regularly 4 Providing mouth care 5 Positioning the infant on the side

Monitoring continuously Assessing skin regularly Providing mouth care Positioning the infant on the side The nurse needs to monitor the oxygen therapy continuously because the infant's status can change rapidly and the oxygen concentration parameters may need to be changed. The nurse also assesses the infant's skin regularly, because excessive rubbing on the bedsheet can increase the risk of skin breakdown. The nurse provides good oral hygiene (mouth care) using sterile water to prevent the drying effect of the oxygen therapy. Positioning the infant on the side helps maintain an open airway. Suctioning is used only as needed, because there is risk of increased intracranial pressure and hypoxia.

The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe? 1 Large for gestational age (LGA) and an infant of a diabetic mother 2 Small for gestational age (SGA) and intrauterine growth restriction 3 Singleton gestation and female 4 Multiple gestation and low birth weight

Multiple gestation and low birth weight Neonatal risk factors include multiple gestation and low birth weight. LGA and infant of a diabetic mother are not neonatal risk factors. SGA and intrauterine growth restriction are not neonatal risk factors. Singleton and female are not neonatal risk factors.

The nurse observes respiratory distress in an infant with phrenic nerve palsy. What action does the nurse take to facilitate expansion of the uninvolved lung? 1 Positions the infant on the affected side 2 Obtains a prescription for oxygen therapy 3 Obtains inhaled nitric oxide (INO) 4 Provides skin-to-skin (kangaroo) contact

Positions the infant on the affected side In infants with phrenic nerve palsy, the lung on the affected side does not expand. Therefore the nurse positions the infant on the affected side to facilitate maximum expansion of the uninvolved lung. Oxygen therapy is initiated in case of severe respiratory distress if other measures to revive the infant fail. INO is effective for severe respiratory distress and respiratory failure in neonates. Skin-to-skin contact is helpful in maintaining appropriate body temperature; it does not facilitate respiration.

Which action does the nurse take while assessing a 40-week-old infant who exhibits symptoms such as vomiting, dehydration, and poor nutrition a few days after birth? 1 Evaluates the Kleihauer-Betke (KB) assay to understand the fetal history 2 Uses the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) 3 Evaluates maternal history for possibility of alcohol ingestion during pregnancy 4 Asks the parent to participate in a drug rehabilitation program

Uses the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) The nurse uses NNNS to identify infants at risk due to intrauterine drug exposure. The tool measures stress, state, neurologic status, and muscle tone in the infant. The KB assay is not a priority after the infant is born because the test is used to detect transplacental bleeding. Evaluating maternal history for alcohol ingestion is secondary because the infant needs to be assessed for further risks. The nurse may advise the parent to participate in a drug rehabilitation program for the parent's well-being. However, it is secondary in this case.

The nurse is caring for a healthy European neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? 1 Bluish-black areas on the body 2 Desquamation of the epidermis 3 Vernix caseosa covering the body 4 Dark red-colored swellings on the body

Vernix caseosa covering the body After 35 weeks of gestation, the newborn's body gets covered with vernix caseosa, which resembles a cheesy white substance and is fused with the epidermis of the skin. It is formed to protect the fetus' skin from the contents of the uterus. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. Desquamation (peeling) of the skin occurs a few days after birth. Mongolian spots are characterized by bluish-black pigmentation of the skin and are generally observed in the Mediterranean, Latin America, Asia, or Africa newborns. They are not usually observed in European newborns. A nevus vascularis is a common type of capillary hemangioma, in which the infant develops dark red-colored swellings. As the child is healthy, the nurse will not find dark red-colored lesions on the body.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: 1 hypertonia, tachycardia, and metabolic alkalosis. 2 abdominal distention, temperature instability, and grossly bloody stools. 3 hypertension, absence of apnea, and ruddy skin color. 4 scaphoid abdomen, no residual with feedings, and increased urinary output.

abdominal distention, temperature instability, and grossly bloody stools. Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric aspirates, and oliguria are signs of NEC.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: 1 congenital infection progresses slower than health care-associated infection. 2 health care-associated infection can be prevented by effective handwashing. 3 infections occur with about the same frequency in boy and girl infants, although female mortality is higher. 4 the clinical sign of a rapid, high fever makes infection easier to diagnose.

health care-associated infection can be prevented by effective handwashing. Handwashing is an effective preventive measure for health care-associated infections because these infections come from the environment around the infant. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly than health care-associated (late onset) infections.

The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: 1 wash the top of the can and can opener with soap and water before opening the can. 2 adjust the amount of water added according to the weight gain pattern of the newborn. 3 add some honey to sweeten the formula and make it more appealing to a fussy newborn. 4 warm formula in a microwave oven for a couple of minutes before feeding.

wash the top of the can and can opener with soap and water before opening the can. Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for a parent to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it.