Maternity and Peds Exam 4

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?

"The baby takes the first breath when ready to leave the uterus."

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery.Reassure them that the caput will decrease in a few days without treatment

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,:

Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?

Infants born to women who are morbidly obese are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

Placental factors; Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption, malformed and smaller placentas, with placental previa or placental insufficiency being the main placental causes.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine

The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?

The nurse would assess the epispadias on the dorsal (top) surface of the penis. This condition often occurs with exstrophy of the bladder.

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?

To obtain accurate assessment of whole body temperature, a skin temperature probe should be placed over the liver if the newborn is supine or in the side-lying position

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn?

convection and evaporation; Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss by convection happens when air currents blow over the newborn's body. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. Heat loss also occurs by radiation to a cold object that is close to, but not touching, the newborn.

How does the nurse position the infant experiencing respiratory difficulty?

on the back with the head elevated 15 degrees

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?

ABCDs of newborn resuscitation include: airway maintenance by placing infant's head in "sniffing" position; suction the mouth, then the nose; suction the trachea if meconium-stained and newborn is NOT vigorous (strong respiratory effort, good muscle tone, and heart rate 100 bpm).

The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment finding?

An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex.

The nurse is caring for a newborn client newly diagnosed with developmental dysplasia of the hip (DDH). Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

Developmental dysplasia of the hip (DDH) is a congenital newborn condition that requires immediate intervention.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome.

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding?

Nevus flammeus, also called a port wine stain, may be associated with structural malformations, bony or muscular overgrowth, and certain childhood cancers and should be monitored with periodic examinations

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level.

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?

Preterm newborns are at a greater risk for cold stress than term or postterm newborns. Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis. Preterm infants lack the ability to shiver in response to cold stress.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?

The infant's mother probably had diabetes.

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate?

The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life.

The nurse is providing education to the parents of an infant who was just diagnosed with transposition of the great arteries. The parents ask, "Which vessels were involved?" The nurse is correct to educate about:

The nurse is correct to educate that in the congenital condition known as transposition of the great arteries, it is the aorta and the pulmonary artery that are reversed.

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

The nurse should assess for meconium aspiration syndrome in the newborn. Meconium aspiration involves patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis that can be seen through chest X-rays

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?

The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn.

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client?

When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.

A nurse is conducting an in-service program for a group of nurses newly hired to work in the labor and birth unit. Part of the program focuses on the neonate and the various mechanisms of heat loss that can occur. Place the mechanisms below in the order that the nurse would describe them as accounting for heat loss from greatest to least

radiation convection evaporation conduction

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery