Maternity and Women's Health Nursing-Caring for a newborn
Absence or weakness of which reflex during the newborn assessment should the nurse report to the health care provider? A.Gag B.Moro C.Babinski D.Tonic neck
A.Gag Absence or diminution of the gag reflex could be life threatening. The infant might aspirate mucus or a feeding. The Moro, Babinski, and tonic neck reflexes may be delayed if the mother has been anesthetized.
What is the percentage of total body water in a premature newborn? A.55% B.65% C.75% D.85%
D.85% The total body water in a premature newborn is 85%. In full-term infants, body water ranges from 70% to 80%. The total body water in a child between the ages of 1 and 12 is approximately 64%.
In a noisy room, a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the mostappropriate nursing action in response to this behavior? A.Document an intact reflex. B.Assess the infant's vital signs. C.Test the infant's ability to hear. D.Stimulate the infant's respirations.
A.Document an intact reflex. The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the response to the stimulus decreases; this decrease in response is called habituation and is expected. Assessing the infant's vital signs and stimulating the infant's respirations are not necessary because the neonate's response is expected. The infant is responding to noise and therefore hears.
A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding? A.Large for gestational age (LGA) and term B.LGA and preterm C.Appropriate for gestational age (AGA) and term D.AGA and preterm
B.LGA and preterm This neonate is preterm (less than 37 weeks' gestation) and LGA; the expected weight at 36 weeks' gestation is between 4 lb 3 oz and 7 lb 1 oz (1900 and 3200 g).
While inspecting her newborn, a mother asks the nurse whether her baby has flat feet. How should the nurse respond? A."Flat feet are more common in children than adults." B."That's hard to assess because the feet are so small." C."There may be a bone defect that needs further assessment." D."Infants' feet appear flat because the arch is covered with a fat pad."
D."Infants' feet appear flat because the arch is covered with a fat pad." A fat pad covers the arch in newborns and infants; the arch develops when the child begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant; arch development is related to walking. Flat feet are not associated with deformities of the bones.
A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication? A.A disease acquired in utero B.An X-linked inheritance pattern C.A tumor arising from muscle tissue D.An injury to the brachial plexus during birth
D.An injury to the brachial plexus during birth The brachial plexus is injured by excessive pressure during a difficult birth or during a vaginal breech birth. Erb palsy is an injury that occurs during the birth process; it is not acquired before or after birth. Erb palsy is not a genetic problem or a tumor arising from muscle tissue.
A large-for-gestational-age (LGA) full-term infant should be monitored for which risk? A.Hypotension B.Hypothermia C.Hypocalcemia D.Hypoglycemia
D.Hypoglycemia Infants who are LGA are considered at risk for hypoglycemia, and their glucose should be monitored following a protocol. LGA infants are not at an increased risk for hypotension, hypothermia, or hypocalcemia.
Which newborn finding would be the mostconcerning? A.Mottling B.Mongolian spot C.Erythema toxicum D.Generalized petechiae
Generalized petechiae are associated with a clotting factor deficiency or an infection. Mottling, Mongolian spot, and erythema toxicum are normal newborn findings.
The nurse concludes that a couple with a newborn with Erb palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion? "Surgery will correct the palsy." "This is a progressive disorder with no cure." "Recovery usually occurs in about 3 months." "Physical therapy will be necessary for 1 year."
"Recovery usually occurs in about 3 months." The nerves that are stretched take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis usually is excellent. Physical therapy is necessary for about 3 months, not a year. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.
A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? A.Flaring nares B.Acrocyanosis C.Heartbeat of 140 beats per minute D.Respirations of 40 beats per minute
A.Flaring nares Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats per minute is an expected finding in the newborn. A respiratory rate of 40 breaths per minute is an expected finding in the newborn.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH ( Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections) infections. How and when may it have been transmitted to the newborn? A.In utero through the placenta B.In the postpartum period through breast milk C.During birth through contact with the maternal vagina D.After the birth through a blood transfusion given to the mother
A.In utero through the placenta Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.
The nurse is assessing a 12-hour-old newborn. Which clinical finding should be reported to the health care provider in a timely manner? A.Jaundice B.Cephalohematoma C.Erythema toxicum D.Edematous genitalia
A.Jaundice Jaundice occurring in the first 24 hours of life is pathologic; it is associated with Rh or another blood incompatibility. Cephalohematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented, it does not require treatment. Erythema toxicum is newborn dermatitis and is believed to be an inflammatory response. The rash is harmless, and although it should be documented, it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, how does the nurse identify them? A.Milia B.Lanugo C.Whiteheads D.Mongolian spots
A.Milia Milia are common, they are not indicative of illness, and they eventually disappear. Lanugo is fine, downy hair. Whiteheads are a lay term for milia; the term is not used in documentation. Mongolian spots are bluish-black areas on the buttocks that may be present on dark-skinned infants.
The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately? A.Placing the naked infant on the scale B.Removing the infant's clothes except for the diaper before weighing C.Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight D.Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight
A.Placing the naked infant on the scale Placing the naked infant on the scale is the most accurate method of weighing an infant because it removes all variables that could influence the weight. Removing the infant's clothes except for the diaper before weighing will result in an inaccurate measurement because the diaper and its contents have mass and will add to the measurement. Weighing the infant's clothes and then subtracting that weight from the infant's weight adds an unnecessary step to the procedure. An adult scale does not have the fine increments that are needed to obtain an accurate weight for an infant.
A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood? A.Putting a hat on the infant's head B.Hydrating the infant every 15 minutes C.Providing stimulation every 15 minutes D.Maintaining a high oxygen concentration
A.Putting a hat on the infant's head Oxygen has a cooling effect, and the infant should be kept warm so that metabolic activity and oxygen demands are not increased. Hydrating the infant every 15 minutes could produce fluid overload, which could in turn lead to increased cardiac output, which is an undesired outcome, especially for an infant with respiratory distress. Providing stimulation every 15 minutes will tire the infant and increase the need for oxygen. Oxygen concentration is determined on the basis of blood gas levels and oximetry and is adjusted accordingly by the health care provider.
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. Which is the nurse's initial action? A.Suctioning the mouth B.Administering oxygen C.Notifying the health care provider D.Initiate chest compressions
A.Suctioning the mouth To maintain a patent airway and promote respiration and gaseous exchange, the nurse's priority action is removing mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The health care provider should be notified if oral suctioning does not clear the airway. If suctioning the mouth and administering oxygen does not improve the newborn's health status, the nurse would need to initiate chest compressions.
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth for what reason? A.To promote the synthesis of prothrombin B.To facilitate the growth of intestinal flora C.To limit an increase in the serum bilirubin level D.To decrease the level of calciferol until the kidneys have matured
A.To promote the synthesis of prothrombin Vitamin K stores are almost absent in the newborn because the intestinal flora that produce this vitamin are not present; vitamin K is an essential precursor of prothrombin, which is part of the clotting mechanism. The intestinal flora develop as the newborn is exposed to extrauterine living conditions. An increased serum bilirubin level may occur in the newborn because of the rapid breakdown of red blood cells and the immature liver's inability to conjugate such large amounts; it is not related to vitamin K. A newborn's kidneys operate at a functional level appropriate to the needs of a healthy newborn, and kidney maturity and calciferol are not related to vitamin K.
Which statement made by the parent of an infant receiving phototherapy for jaundice would cause concern? A."I keep track of the number of wet diapers." B."My baby's skin is dry, so I applied a little lotion. C."I placed my baby under the lights dressed only in a diaper." D."I closed my baby's eyes before placing the mask over them."
B."My baby's skin is dry, so I applied a little lotion. Lotions, creams, and ointments should not be applied to the infant's skin during phototherapy because it can absorb heat and cause burns. The infant should be placed under the phototherapy lights dressed only in a diaper. The number of wet or soiled diapers is monitored because it is an indicator of the infant's hydration status. The eyes of the infant should be closed before placing the mask over the eyes to prevent scratching of the cornea.
One minute after birth, a nurse assesses a newborn and auscultates a heart rate of 90 beats per minute. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score? A.9 B.8 C.7 D.6
B.8 A heart rate slower than 100 beats per minute receives 1 point, and color (acrocyanosis: body pink, extremities blue) receives 1 point; the respiratory rate, muscle tone, and reflex irritability each get a score of 2, for a total of 8. A score of 9 is too high. An Apgar score of 7 is too low, as is a score of 6
A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the action of this therapy? A.Stimulates the liver to dispose of the bilirubin B.Breaks down the bilirubin into a conjugated form C.Facilitates the excretion of bilirubin by activating vitamin K D.Dissolves the bilirubin, allowing it to be excreted by the skin
B.Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.
A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond? A.By suggesting that she arrange for help at home B.By asking her to describe her concerns more fully C.By telling her to speak to her health care provider about her concerns D.By recommending that she schedule times when family members can assist her
B.By asking her to describe her concerns more fully Information-seeking is the first step in problem solving. Suggesting that the client arrange for help at home is presumptuous and possibly too expensive. The nurse should not make decisions for the client. Telling her to speak to her health care provider shifts the responsibility to the health care provider; the nurse should explore the client's concerns. Recommending that she schedule times when family members can assist her is presumptuous because it assumes that the family is willing and able to help.
The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that does what? A.Becomes ecchymotic B.Crosses the suture line C.Increases after several hours D.Is tender in the surrounding area
B.Crosses the suture line Scalp edema that crosses the suture line is the sign that differentiates between these two conditions; with caput succedaneum the swelling crosses the suture line, whereas it does not in cephalhematoma. Ecchymosis may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will have to be observed for signs of increased intracranial pressure. Tenderness is not associated with either condition.
A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? A.Hypovolemia B.Hypoglycemia C.Hypercalcemia D.Hypothyroidism
B.Hypoglycemia SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. Decreased blood pressure, pallor with cyanosis, tachycardia, retractions, lethargy, and a weak cry are signs of hypovolemia. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.
A neonate has phenylketonuria (PKU). Which information would the nurse include in a discussion with the parents when explaining what caused their infant's problem? A.Failure to pass meconium B.Inborn error of metabolism C.Severe eczematous skin rash D.PreSence of an extra chromosome
B.Inborn error of metabolism PKU is an inborn error of metabolism. Meconium ileus may occur if the newborn has cystic fibrosis, an intestinal obstruction, or an imperforate anus. A skin rash is not a sign of PKU. Trisomy is a chromosomal anomaly, the most common of which results in Down syndrome
Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? A.Duration of cry B.Respiratory distress C.Frequency of voiding D.Decreased temperature
B.Respiratory distress Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. The temperature of the preterm infant is expected to decrease because of immature thermoregulation.
The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? A.The tongue is securely on top of the nipple. B.The mouth covers most of the areolar surface. C.Loud sucking sounds are heard during the 15 minutes spent at each breast. D.Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.
B.The mouth covers most of the areolar surface. Effective attachment involves covering most of the areolar surface of the breast with the newborn's mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn's tongue. Loud sucking sounds indicate inadequate attachment. The newborn should suckle for a longer period than 5 minutes; the newborn may be sucking only on the nipple.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? A.Covering the trunk to prevent hypothermia B.Using shields on the eyes to protect them from the light C.Massaging vitamin E oil into the skin to minimize drying D.Turning after each feeding to reduce exposure of each surface area
B.Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.
After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? A."I will suction the nares first." B."I will keep the bulb syringe nearby." C."I will depress the bulb before suctioning the mouth or nose." D."I will insert the tip of the bulb syringe in the center of the mouth."
C."I will depress the bulb before suctioning the mouth or nose." The bulb syringe is depressed before suctioning the mouth or the nose. The mouth should be suctioned first. The bulb should be kept in the crib at all times. When suctioning the mouth, the tip of the bulb should be inserted into one side of the mouth to avoid stimulating the gag reflex.
A nurse assesses a newborn 1 minute after birth. The body is pink with blue extremities; the heart rate is 122 beats per minute; the legs are withdrawn when the soles are flicked, respiration is easy, with no evidence of distress; and the arms and legs are flexed and moving vigorously. What Apgar score should the nurse document in the newborn's medical record? A.7 B.8. C.9 D.10
C.9 One point was removed from the Apgar score because the extremities are blue. Scores of 7 and 8 are too low and do not reflect the status of the newborn. A score of 10 is too high and does not reflect the status of the newborn.
A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of infection-control precautions should the nurse institute? A.Enteric B.Contact C.Droplet D.Standard
C.Droplet Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.
Two days after birth a neonate's head circumference is 16 inches (40 cm), and the chest circumference is 13 inches (32.5 cm). Which would the nurse infer from these measurements? A.Microcephaly B.Narrow chest C.Enlarged head D.Expected head size
C.Enlarged head Average head circumference in the healthy newborn is 13.2 to 14 inches (33 to 35 cm), about 1 inch (2.5 cm) larger than the chest circumference. An enlarged head may indicate hydrocephalus. Microcephaly indicates that the head is smaller than expected, not larger. The chest circumference of 13 inches (32.5 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large.
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How would this observation be documented? A.Stork bites B.Forceps marks C.Mongolian spots D.Ecchymotic areas
C.Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.
Which finding for a 4-hour-old newborn would be most concerning for the nurse? A.Acrocyanosis B.Irregular heartbeat C.Paradoxical respiration D.Apical pulse in the fourth intercostal space
C.Paradoxical respiration Paradoxical respiration is an exaggerated rise in the abdomen with respirations as the chest falls (instead of the infant exhibiting abdominal respirations); this type of breathing is abnormal and should be reported. Acrocyanosis is a bluish discoloration of the hands and feet, which is a normal finding in the first 24 hours after birth. An irregular heartbeat is not uncommon for the first few hours of life. The apical pulse in a newborn is located in the fourth intercostal space.
A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time? A.Bringing the infant as requested before she changes her mind B.Describing how the infant looks before bringing the infant to her C.Staying with her after bringing the infant to help her verbalize her feelings. D.Showing the mother pictures of the birth defects, then bringing the infant to her
C.Staying with her after bringing the infant to help her verbalize her feelings. Allowing the client time to talk about her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature.
A healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse identify? A.Moro B.Babinski C.Tonic neck D.Palmar grasp
C.Tonic neck The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month. The Moro reflex is exhibited when a sudden change in equilibrium causes extension and abduction of the extremities followed by flexion and adduction. The Babinski reflex is exhibited when the examiner runs a finger up the lateral (small toe side) undersurface of the foot from the heel to the toes and then across the ball of the foot; the toes separate and flare out in response. The palmar grasp reflex is exhibited when the fingers flex around a person's finger placed in the infant's palm.
A nurse determines that a newborn has a cephalohematoma. What did the nurse note? A.Ridges where the cranial bones overlap B.Edema involving the scalp over the occipital area C.Pulsation of the cerebral arteries in the anterior and posterior fontanels D.Bleeding between the parietal bone and periosteum confined within the suture line
D.Bleeding between the parietal bone and periosteum confined within the suture line Cephalohematoma is a collection of blood localized between the periosteum and the bony cranium caused by the rupture of blood vessels during the birth process; it does not cross suture lines. Overriding sutures cause ridges, not swelling. Edema involving the scalp over the occipital area is a description of caput succedaneum, which results from pressure on the occiput during labor; it is outside the periosteum and spreads throughout the scalp. Pulsations may be seen and palpated in the anterior fontanel, but they are not related to a cephalohematoma.
A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate? A.Assess the penis daily for signs of bleeding. B.Apply petroleum jelly to the penis for 1 week. C.Pull the foreskin back once a day for 1 month. D.Clean the penis with warm water at each diaper change.
D.Clean the penis with warm water at each diaper change. Cleaning the infant's penis preserves the skin's acid mantle, which is a protective mechanism. Diaper wipes, soaps, oils, and lotions can alter this acid mantle and should be avoided when the penis is cleaned. Assessing the penis for signs of bleeding is recommended care for the infant who has been circumcised. Applying petroleum jelly to the penis for 1 week is recommended to prevent adherence to the diaper in the infant who has been circumcised. Retracting the foreskin may cause constriction around the penile shaft and is not recommended. A tight prepuce (foreskin) is common in newborns; the prepuce may not be retractable for 3 to 4 years.
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. Which condition of the newborn is associated with hydramnios? A.Cardiac defect B.Kidney disorder C.Diabetes mellitus D.Esophageal atresia
D.Esophageal atresia Esophageal atresia is associated with hydramnios. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes mellitus in the newborn is not associated with hydramnios.
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent? A.Radiation B.Convection C.Conduction D.Evaporation
D.Evaporation Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.
An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home? A.Visibility of the sclerae above the irises B.Violent involuntary muscle contractions C.Excessive fluid accumulation in the abdomen D.Fever accompanied by decreased responsiveness
D.Fever accompanied by decreased responsiveness Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. The peritoneum absorbs cerebrospinal fluid adequately; ascites is not a problem.
A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4-lb 12-oz infant. Which condition would this information suggest? A.Prematurity B.Cardiac anomalies C.Respiratory infection D.Intrauterine growth restriction
D.Intrauterine growth restriction The pathologic changes of maternal chronic vascular disease cause uteroplacental insufficiency; vasospasms diminish fetal oxygenation and nutrition, which leads to intrauterine growth restriction. Prematurity is defined as gestational age of less than 37 weeks. There is not a greater incidence of cardiac anomalies in infants with intrauterine growth restriction. There is also not a greater incidence of respiratory infection in infants with low birth weight; however, they may have a lower resistance to infection.
A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of potential interventions for the neonate. Which is the priority intervention? A.Promoting bonding B.Preventing infection C.Supporting temperature D.Maintaining respirations
D.Maintaining respirations If the airway is not patent and gas exchange is inadequate, life cannot be sustained; therefore, maintaining respiration is the priority. Although bonding is important to the parent-child relationship, without oxygen life is not sustained. Although preventing infection is important, without oxygen life is not sustained. Although body temperature is important because the preterm neonate is lacking brown fat and other defense mechanisms needed to maintain temperature, without oxygen life is not sustained.
During the second reactive period, a newborn becomes more alert and responsive, and there is an increase in mucus production and gagging. Which would the nurse do first? A.Report this finding. B.Administer nasal oxygen. C.Lower the head of the bassinet. D.Remove secretions from the pharynx.
D.Remove secretions from the pharynx. An increase in mucus production is expected during the second reactive period; mucus should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinet may help secretions drain, the newborn cannot remove secretions that block respirations.
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent? A.Cataracts B.Strabismus C.Ophthalmia neonatorum D.Retinopathy of prematurity
D.Retinopathy of prematurity Retinopathy of prematurity is caused by the high concentration of oxygen that may have to be used to support some preterm neonates; oxygen must be administered cautiously and, depending on the neonate's blood oxygen level, adjusted accordingly. Cataracts and strabismus (crossed eyes) are not caused by a high oxygen concentration. Ophthalmia neonatorum refers to an inflammation of the eyes caused by a gonorrheal or chlamydial infection contracted as the fetus passes through the birth canal.
