Nu 472 EAQ#1

Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct. 1. Crying 2. Tachypnea 3. Diaphoresis 4. Tachycardia 5. Hypertension

1. Crying Crying is a behavioral response. Tachypnea, diaphoresis, tachycardia, and hypertension are physiological responses to pain.

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?

"This is expected. Your baby is trying to focus."

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? 1. Duration of cry 2. Respiratory distress 3. Frequency of voiding 4. Poor nutritional intake

2. 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. If the infant is in respiratory distress, the nutritional intake is not important.

Which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area? 1. Remove the cord clamp only after the cord stump has separated. 2. Smooth ointment or baby lotion around the cord after the sponge bath. 3. Leave the area untouched or clean with soap and water; then pat it dry. 4. Wrap an elastic bandage snugly around the waist area over the cord site.

3. Healing is optimal when the area is left alone or, if needed, is washed with mild soap and water and then gently dried. The cord clamp is removed when the cord stump is dry, usually at 24 hours. Ointment and other emollients will keep the cord moist; rapid drying of the cord is preferred. Wrapping an elastic bandage snugly around the waist area over the cord site prevents the cord from drying and provides a dark, warm, moist medium for the growth of organisms.

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery? 1. Stimulating crying 2. Administering oxygen 3. Placing the newborn on the mother's chest 4. Providing for suctioning of the oropharynx as the head emerges

4. Providing for suctioning of the oropharynx as the head emerges The color of the amniotic fluid is indicative of meconium staining; the practitioner must therefore prepare for the potential fetal aspiration of meconium. The newborn should not be stimulated to cry until the airway has been cleared of meconium. Oxygen is administered only after a patent airway is established and if needed. Putting a moist saline dressing on the cord stump is unnecessary because there is no indication that umbilical cord blood or a transfusion is needed.

which would the nurse include in a teaching plan for a new mother and her infant?

A demonstration and explanation of infant care

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:

Breakdown of fetal red blood cells

A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn? 1. Injury 2. Infection 3. Feeding problem 4. Respiratory distress

Infection

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?

The mouth covers most of the areolar surface. Parents need support and reassurance that their newborn is not permanently damaged. Cephalohematomas do not cause impaired neurological function

Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. 1. Infection 2. African-American race 3. Prematurity 4. Breast-feeding 5 Formula feeding 6. Maternal diabetes

1, 3, 4 & 6 Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Newborns of East Asian race have a higher risk factor than African-Americans to develop jaundice. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.

Which intervention would the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? 1. Fast-acting insulin 2. Special high-risk care 3. Routine newborn care 4. Limited glucose intake

2. The infant of a diabetic mother is a newborn at risk because of the interaction between the maternal disease and the developing fetus. The newborn of a mother with type 1 diabetes generally is hypoglycemic because of oversecretion of insulin by the newborn's hypertrophied pancreas. The newborn of a mother with type 1 diabetes is at high risk and requires intensive care. The newborn of a mother with type 1 diabetes is prone to hypoglycemia and will probably need increased glucose.

Which behavior does the infant exhibit if an adequate amount of milk is being ingested?

Voids six or more times a day

Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

gamma globulin The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

Which characteristic that may pose a potential nutrition problem would the nurse identify in a preterm neonate? 1. Inadequate sucking reflex 2. Diminished metabolic rate 3. Rapid digestion of formula 4. Increased absorption of nutrients

1. The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting. The metabolic rate is increased because of fatigue and growth needs. The digestive process is slow, especially in regard to the ability to digest lipids. Absorption of nutrients is decreased because the gastrointestinal tract is immature.

Which is the priority nursing action to assist an anxious father in his concern about not bonding with his newborn? 1. Encouraging the father's participation in a parenting class 2. Providing time for the father to be alone with and get to know the baby 3. Offering the father a demonstration on newborn diapering, feeding, and bathing 4. Allowing time for the father to ask questions after viewing a film about a new baby

2. Providing time for the father to be alone with and get to know the baby Time alone provides the opportunity for paternal-infant attachment/bonding.Touching the infant may reduce some of the father's anxiety. Although helpful, a parenting class does not meet the need for paternal-infant attachment/bonding. A demonstration on newborn diapering, feeding, and bathing does not acknowledge the father's anxiety; also, he may not be ready to absorb this information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach to the father's emotional needs and does not address the father's concerns.

In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? A. Documenting an intact reflex B. Assessing the infant's vital signs C. Testing the infant's ability to hear D. Stimulating the infant's respirations

A. Documenting 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.

Which behavior does a nurse expect of a newborn approximately 1 hour after birth? A. Crying and cranky B. Hyperresponsive to stimuli C. Relaxed and sleeping quietly D. Intensely alert with eyes wide open

C. Relaxed and sleeping quietlyIt is expected that a newborn will enter a sleep phase about 30 minutes after birth. After the initial cry, the baby will settle down and become quiet and alert. Hyperresponsiveness to stimuli occurs after the first sleep. Intense alertness with eyes wide open occurs during the first period of reactivity.