Newborn
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? I will be sure to wash my hands before and after bathroom use." "I need to breast-feed, especially for the first 6 weeks postpartum." "Support groups are available to assist me with understanding my diagnosis of HIV." "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
"I need to breast-feed, especially for the first 6 weeks postpartum." Rationale: The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. HIV-positive clients should be encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.
Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. Grunting respirations Presence of vernix caseosa Heart rate of 190 beats/minute Anterior fontanelle measuring 5.0 cm Bluish discoloration of hands and feet A yellow discoloration of the sclera and body
Grunting respirations Heart rate of 190 beats/minute A yellow discoloration of the sclera and body Rationale: Grunting respirations is a sign of possible respiratory distress. The normal newborn heart rate is 100 to 160 beats/minute. The presence of a yellow discoloration could indicate newborn jaundice. Options 2, 4, and 5 are normal findings. The anterior fontanelle should measure 5 cm wide by 2-3 cm long.
The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. Retinopathy Hypoglycemia Fractured clavicle Hyperbilirubinemia Congenital heart defect Necrotizing enterocolitis
Hypoglycemia Fractured clavicle Congenital heart defect Rationale: Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are also at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect). Retinopathy is a disorder that affects the developing vessels of preterm infants. Hyperbilirubinemia is not an immediate risk related to LGA. Preterm birth is the most prominent risk factor in the development of necrotizing enterocolitis.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. Avoid stimulation. Decrease fluid intake. Expose all of the newborn's skin. Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.
Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches. Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.
The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. Call bell Feeding pump Vital sign machine Phototherapy lights Intravenous (IV) pump
Phototherapy lights Intravenous (IV) pump Rationale: Given the fact that the newborn is 4 days old, accurate delivery and prevention of circulatory overload is a priority. The IV fluid rate must be maintained using an IV pump. Fluids by gravity would not be the safest mode of delivery in a newborn. The phototherapy lights must be used continually to be effective. The newborn can be fed via gravity using the gavage method if necessary. Vital signs may be obtained without powered equipment. The caregiver may require a call bell, but there are other options for a call device, such as a hand-held noisemaker or whistle.
