Neonatal Assessment

A client has a child with Tay-Sachs disease and wants to become pregnant again. She tells the nurse, "I'm worried it will happen again." How should the nurse respond?

"Have you considered the option of genetic counseling?" Rationale: Asking the client whether she has considered genetic counseling ensures that the client is informed of the need for genetic counseling and gives her an option for decision-making. Asking the client whether she has discussed this with her primary health care provider shifts the responsibility to the practitioner; the nurse should be involved in teaching about resources. Asking the client whether Tay-Sachs has occurred in her family does not address the client's concern and changes the focus of the discussion. Although the disease is rare in the general population, it is an inherited autosomal recessive disorder and there is a 25% probability that it will occur again in the same family.

A newborn boy is placed on his mother's abdomen immediately after birth and starts to suck on his fist. His mother asks the nurse, "Why is he doing that?" What is the most appropriate response by the nurse?

"Sucking prepares him for when he starts to nurse later." Rationale: An active sucking reflex is a typical response of a healthy full-term newborn, especially after an uneventful birth. Newborns show distress by vigorous crying, not by sucking. A neonate sucks at various times; sucking is a reflex in the newborn and is not the sole indicator of hunger.

A nurse teaches a couple about care of their newborn, who has been circumcised. The nurse concludes that the teaching is effective when the father says:

"We should apply petrolatum gauze to the penis." Rationale: Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Yellow exudate is expected; it is not a sign of an infectious process.

An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the infant. Which dosage and route will the nurse use?

0.5 to 1.0 mg given intramuscularly Rationale: The correct dosage of vitamin K is 0.5 to 1.0 mg, and the correct route is intramuscular. Vitamin K is not given to infants subcutaneously.

The nurse is performing a gestational age assessment, using the New Ballard Scale. According to the following information and graph, at how many weeks gestation is the newborn? Total Neuromuscular: 16 Total Physical Maturity: 20

38 Rationale: The fetus is at 38 weeks' gestation. Add the total neuromuscular score of 16 to the total physical maturity score of 20 for a total of 36. Look under the score total score column and you will find that the closest number to the total score of 36 is 35. Staying on the same row, move right, to the Gestational Age column, where you will find the gestational age of 38 weeks

While assessing a newborn suspected of having Down syndrome, what does the nurse expect to note?

A single line across each palm Rationale: A single line across the palm of each hand, a characteristic finding in newborns with Down syndrome, is known as a simian crease. Stubby fingers and small ears, not long, slim fingers and large, protruding ears, are commonly found in newborns with Down syndrome. Newborns with Down syndrome have hypotonic, not hypertonic, muscles.

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?

Administering additional fluids every 2 hours Rationale: Insensible and intestinal fluid losses are increased during phototherapy; extra fluid prevents dehydration. Taking the vital signs every hour is unnecessary unless a change from the baseline occurs. The eye shields should be removed for feeding and when the infant is being held. The total body needs to be exposed to the light.

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?

Applying sterile, moist nonadherent dressings to the sac Rationale: Applying sterile, moist nonadherent dressings is done to prevent drying and breakage of the sac; any opening increases the risk for infection of the central nervous system. Diapering is contraindicated until the defect is repaired; the diaper may irritate the sac and cause rupture, predisposing the infant to infection. The infant is generally placed in a neutral position to reduce pressure on the affected area. The legs are abducted to counteract subluxation because the infant is unable to move the legs.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?

Avoid squeezing them and don't try to wash them off. Rationale: Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. The white material is not purulent and is not infectious.

A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that she has shoulder pain. The nurse concludes that the pain is caused by:

Blood accumulation under the diaphragm Rationale: Any blood from the rupture will accumulate, causing phrenic nerve irritation and pain. Shoulder pain is not a response to anxiety; it is a typical symptom of phrenic nerve irritation. The cardiac changes caused by hypovolemia do not cause shoulder pain. A ruptured tube can cause rebound tenderness in the abdomen, not the shoulder.

A nurse is assessing a newborn in the birthing room. What finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life?

Central cyanosis Rationale: Cyanosis of the lips, mucous membranes, and face indicates diminished oxygenation of the blood, caused by either decreased lung expansion or right-to-left shunting of blood. Flexed extremities are expected in the healthy newborn. A heart rate of 130 beats/min is expected in the healthy newborn. A respiratory rate of 40 breaths/min is expected in the healthy newborn.

After a spontaneous vaginal delivery the client expresses concern because the newborn has a red rash with small papules on the face, chest, and back. What condition does the nurse recognize?

Erythema toxicum Rationale: Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears after short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body with red skin on one side, and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeus, or port wine stain, a reddish-purple capillary angioma below the dermis.

The nurse is conducting an initial assessment of a recently delivered newborn. Which assessment requires immediate action by the nurse?

Expiratory grunting and nasal flaring Rationale: Expiratory grunting and nasal flaring are signs of respiratory distress in the newborn and require action by the nurse. The normal respiratory rate of a newborn is 30 to 60 breaths/min, so 40 breaths/min is within the normal range. The heart rate should be between 110 and 160 beats/min, so a heart rate of 140 beats/min is within the normal range. Fine crackles may be auscultated for several hours after birth and clear when the newborn vigorously cries.

The nurse identifies a swelling on the scalp when assessing a newborn. What assessment finding indicates a cephalohematoma?

Swelling confined to the area over one skull bone Rationale: A cephalohematoma, or collection of blood between the periosteum and skull bone, is confined to an area over a single cranial bone. Wide suture lines indicate the possibility of hydrocephalus. An ecchymotic area over the affected eye may be the result of a misplaced forceps; it is not characteristic of a cephalohematoma. Skin discoloration may be present for a number of reasons, such as vacuum extraction or forceps trauma.

A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply.

Tachypnea, Exaggerated Moro reflex, Prolonged, high-pitched cry, Restlessness and excessive activity Rationale: In addition to these symptoms, an infant experiencing drug withdrawal has muscle rigidity with increased muscle tone and poor sleep patterns. Such infants are often difficult to console.

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiologic jaundice, a benign condition, caused by:

Immature liver function Rationale: Jaundice occurs because of the expected physiologic breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Breastfed neonates are more prone to physiologic jaundice because of diminished calorie and fluid intake in the 3 days before milk production reaches normal volume. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.

What should the nurse do to enhance a neonate's behavioral development?

Help the parents stimulate their awake baby through touch, sound, and sight. Rationale: Stimuli are provided by way of all the senses; because the infant's behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged. Infants require interactions soon after birth and consistently thereafter, but interactions should occur during the infant's regular waking periods.

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk developing jaundice. Which conditions are risk factors for jaundice? Select all that apply.

Infection, Prematurity, Breastfeeding, Maternal Diabetes Rationale: Infants are at a higher risk of jaundice if they are born prematurely, are exclusively breastfed, have an infection, or their mothers have diabetes. Jaundice is more common in male infants. Infants that are fed formula do not develop jaundice as often as breastfeed babies do.

Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.

Irritability, High-pitched cry, Ineffective feeding behavior Rationale: Pressure on the cerebral structures influences the central nervous system, resulting in irritability. A high-pitched cry is common in neonates with increased ICP. Ineffective feeding behavior is typical of neonates with increased ICP. The fontanels are bulging, not depressed, with increased ICP. Decreased urinary output is related to dehydration and kidney problems, not increased ICP.

A client comes to the fertility clinic for a hysterosalpingography using radiopaque contrast material to determine whether her fallopian tubes are patent. When preparing for the test, the nurse explains to the client that she:

May have some persistent shoulder pain for 14 hours after the test Rationale: The nurse is describing referred pain from passage of the contrast medium through the tubes; it is usually indicative of tubal patency. An anesthetic is not given; the client's complaint of pain can be managed with a position change and mild analgesics. The client may resume usual activities as soon as the test is over. The client usually does not experience nausea or vomiting.

When calculating an Apgar score for a newborn, what does the nurse assess in addition to the heart rate?

Muscle tone Rationale: The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score.

A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the priority nursing action is:

Preparing for a cesarean birth Rationale: The lesions are probably a herpes infection, which can be fatal to the newborn if it is transmitted during a vaginal birth. Herpes is a viral infection that does not respond to antibiotics. A client in active labor will give birth vaginally, before the test results of the smear become available. Standard precautions should be used; double gloving is unnecessary.

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply.

Small breast buds, Wrinkled thin skin, Pinnae that remain flat when folded Rationale: Breast buds are small, with underdeveloped nipples, in the preterm infant. Preterm newborns have little subcutaneous fat; the skin is wrinkled and blood vessels and bony structures are visible. Preterm infants' ears contain little cartilage and are very inelastic when folded; at term, the ears contain cartilage and the pinnae are firm. Sole creases develop progressively during pregnancy and cover the entire foot at term. A preterm male infant's testes are undescended; rugae develop progressively and cover the entire scrotum of the full-term male newborn.

The nurse is caring for a preterm infant in the neonatal intensive care unit. What early sign of neonatal sepsis should the nurse report to the health care provider?

Temperature instability Rationale: In the neonate, early signs of infection are often subtle and can be indicators of other conditions. There may be temperature instability, respiratory problems, and changes in feeding habits or behavior. Early signs of sepsis in the neonate include full anterior fontanels (not flat) and prolonged capillary refill time (not brisk). Increased temperature or hyperthermia is a rare early sign of sepsis in the neonate.

The parents of a newborn who is undergoing phototherapy ask a nurse why their baby's eyes are covered with eye patches. What information should the nurse remember before responding?

They prevent injury to the conjunctiva and retina. Rationale: Eye patches are applied while an infant is undergoing phototherapy to prevent drying of the conjunctiva, injury to the retina, and alterations in biorhythms. The infant will close the eyes automatically in response to bright lights and application of a patch. The infant should be exposed to bright lights periodically so circadian rhythms will become established. Rapid eye movements are automatic during different phases of sleep and will not be affected by eye patches.

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. What infant safety education should be provided? Select all that apply.

1. Wash your hands before touching the newborn 2. All client identification bands should remain in place until discharge. 3. Check the identification of staff and if there is a question of validity, call the nursing station. Rationale: Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn's being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.

A nurse is assessing a newborn with trisomy 21 (Down syndrome). What clinical findings does the nurse expect? Select all that apply.

Protruding tongue, Hypotonic muscle tone, Broad nose with a depressed bridge Rationale: The eyes appear small because of epicanthic folds on the inner corner of the eyelids and the upward slant of the eyes. Impaired hearing is not an expected problem with Down syndrome. The tongue usually protrudes and is sometimes fissured. Infants with Down syndrome have decreased muscle tone, which compromises respiratory expansion, as well as the adequate drainage of mucus. Usually there is one deep crease across the palm of the hand (simian crease). A broad nose with a depressed bridge (saddle nose) is a characteristic of Down syndrome.

A newborn is Rh-positive, and the mother is Rh-negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive Rh-negative blood because:

The red blood cells will not be destroyed by maternal anti-Rh antibodies. Rationale: Giving Rh-positive cells will lead to further hemolysis; Rh-negative cells are not attacked by maternal antibodies in the infant's blood. Blood cells usually do not come from the mother. Rh-negative blood is not neutral; it provides a temporary safeguard from further hemolysis. A reaction to other antigens in the crossmatched blood may occur.

A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first?

The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth Rationale: The appearance of jaundice during the first 24 hours of life or persistence beyond the ages delineated usually indicates a potential pathologic process that requires further investigation. The white blood cell count increase is normal after birth, possibly a result of to stress and tissue trauma during the birthing process. The acceptable range for the newborn heart rate is 110 to 160 beats/min. Saturating more than one pad per hour with lochia rubra is a matter of concern because it is less than the acceptable limit.

The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that:

These areas usually are normal and will fade within the first year. Rationale: Areas of deep-blue coloring on the skin, often seen on the lower back and buttocks, are called Mongolian spots. Mongolian spots are a variation within the norm and disappear in the first year. Mottling caused by cold covers the entire body. The harlequin color change is not purple or blue and involves an entire half of the body. In this newborn these are expected findings; if the baby were light skinned, the possibility of bruises should be investigated.