OB 23, 24

The priority assessment for the Rh-negative infant whose mother's indirect Coombs test was positive at 36 weeks is a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.

A An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor due to erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated specifically to an infant with an Rh incompatibility issue.

A newborn assessment finding that would support the nursing diagnosis of postmaturity would be a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.

A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.

A Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.

A Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the use of positive-pressure oxygenation, which stretches the immature lung membranes.

Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation

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Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth. Which viral infections are most likely to be transmitted during the birth process? (Select all that apply.) a. Hepatitis B b. Rubella c. Herpes d. Varicella Zoster e. Cytomegalovirus

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When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find a. cyanosis. b. diuresis. c. signs of congestive heart failure. d. increased oxygenation of the tissues.

ANS: C Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion and congestive heart failure. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect.

In an infant with cyanotic cardiac anomaly, the nurse should expect to see a. feedings taken eagerly. b. a consistent and rapid weight gain. c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration.

ANS: D With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity.

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of a. RDS. b. PIVH. c. BPD. d. ROP.

B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures.

11. The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice a. may result in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.

B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. This type of jaundice may lead to kernicterus; however, screening and appropriate treatment needs to take place in a time sensitive manner in order to prevent kernicterus.

Which is the most useful factor in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families with Dependent Children d. Women, Infants, and Children (WIC) nutritional program

B Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention of premature births. Lower socioeconomic groups do not seek out health care, which puts them at risk for preterm labor

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.

B Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and removal of bilirubin.

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Intraventricular hemorrhage (IVH) d. Bronchopulmonary dysplasia (BPD)

B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain.

The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.

B Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D10W. d. Document the event in the nurses' notes.

B These symptoms are indications of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain. It is not common practice to administer intravenous glucose to a newborn unless their condition does not allow for enteral feedings.

An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as a. SGA. b. VLBW. c. ELBW. d. low birth weight at term.

B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely low-birth-weight) infants weigh 100 g or less at birth.

The nurse should be alert to a blood group incompatibility if a. both mother and infant are O-positive. b. mother is A-positive and infant is A-negative. c. mother is O-positive and infant is B-negative. d. mother is B-positive and infant is O-negative.

Blood group incompatibilities occur because O-positive mothers who have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O.

While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status

C Because the fetus has already passed meconium in utero, the labor and birth assume a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, therefore airway complications take precedence in terms of nursing diagnosis and medical management.

Which statement regarding large-for-gestational age (LGA) infants is most accurate? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome is the most common complication.

C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Postmaturity syndrome is not an expected complication with LGA infants.

The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant? a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. The infant required warmed humidified oxygen. d. The infant was placed skin to skin with the mother.

C If the infant with meconium in the amniotic fluid is not breathing effectively after drying, stimulation, and bulb syringe suctioning, they may require humidified O2 or positive-pressure ventilation.

What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a. All body parts appear proportionate. b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body. d. One side of the body appears slightly smaller than the other.

C In asymmetric intrauterine growth restriction, the head is normal in size; but, appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant. b. hypoinflation of the lungs. c. inadequate absorption of fetal lung fluid. d. a delayed vaginal birth associated with meconium-stained fluid.

C Inadequate absorption of fetal lung fluid is thought to be the clinical reason for TTN. Lack of surfactant in the premature infant is likely to result in respiratory distress syndrome. A delayed vaginal birth will help prevent TTN.

Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths per minute d. Has an axillary temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute

C Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle-feeding.

Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin. b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes. c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes. d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension.

C Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal.

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy

C Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit.

The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant a. is exhibiting signs of RDS. b. requires tactile stimulation around the clock to ensure that apneic periods do not progress further. c. is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit. d. requires the use of CPAP to promote airway expansion.

C Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths per minute). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN). The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to a. refer them to the neonatologist for more information. b. reassure them not to worry. The infant will be monitored closely by trained staff. c. explain to them that this often occurs following a birth and it will most likely resolve in the next 24 to 48 hours. d. tell them that they will be able to come and see their baby, which will help make calm their anxiety.

C The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents' concern without referral to the pediatric provider

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type

C The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant's bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is a. soft and supple skin. b. a hematocrit level of 55%. c. lack of subcutaneous fat. d. an abundance of vernix caseosa.

C This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n) a. hematocrit level of 58%. b. RBC count of 5 million/mcL. c. WBC count of 15,000 cells/mm3. d. blood glucose level of 25 mg/dL.

D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3

Newborns whose mothers are substance abusers frequently exhibit which of the following behaviors? a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

D Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. These infants may also present with hyperactive muscle tone, a high-pitched cry, and diarrhea.

Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infant's weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 36.1C, 35.5C, and 36.1C (97, 96, and 97F).

D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. Keep charts on top of the incubator so the nurses can write on them there. c. While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. d. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

D Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may under stimulate the infant during those long periods and overtire the infant during the procedures

In comparison with the term infant, the preterm infant has a. more subcutaneous fat. b. well-developed flexor muscles. c. few blood vessels visible through the skin. d. greater surface area in proportion to weight.

D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are features that are more characteristic of a term infant.

Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration. c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings.

D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific to SGA infants. Dehydration is a concern for all infants and is not specific to SGA infants. Respiratory distress syndrome is most commonly seen in preterm infants.

Which of the following lab values indicates that an infant may have polycythemia? a. Hct 50% b. Hct 55% c. Hct 62% d. Hct 70%

D The presence of polycythemia in an infant is characterized by a hematocrit value greater than 65%.

Decreased surfactant production in the preterm lung is a problem because a. surfactant keeps the alveoli open during expiration. b. surfactant causes increased permeability of the alveoli. c. surfactant dilates the bronchioles, decreasing airway resistance. d. surfactant provides transportation for oxygen to enter the blood supply.

Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, surfactant permits enhanced oxygen exchange. Infants treated with surfactant have higher survival rates.