ob exam
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?
Check blood glucose. Explanation: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.
hypoglycemia in newborn
Criteria: < 30 - heel stick < 40 - venipuncture
Self-quieting ability
Hand to mouth, sucking
Motor maturity
Movement become smoother
The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?
On the dorsal end of the penis Explanation: The nurse would assess the epispadias on the dorsal (top) surface of the penis. This condition often occurs with exstrophy of the bladder. The other options are incorrect locations.
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?
Percussion reveals dullness. Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.
Circumsision
RN to ensure: •12 hours of life •One normal void •Vitamin K •No feeds 1 hour before •Consent •ID before procedure •Monitor bleeding •Urinate 24 hours after
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
atony
the 5 Ss to sooth crying baby
swaddle, shushing, side lying, swinging, sucking
True or false: There are 20cal/oz in most breast milk and formula
true
Respiratory Activity Perfusion Position
Initially at birth Reassess often after birth for several hours At discharge
What does LATCH stand for?
L- latch A- audible swallowing T- type of nipple C- comfort H- amount of help mom needs
A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term?
3,500 grams Explanation: Typically, the term newborn weighs 2,500 to 4,000 g. Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation.
Physical Maturity
Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Genitals
It would be best to place an infant with a myelomeningocele in which position prior to surgery?
on the stomach (prone) Explanation: Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion.
what antibody that crosses the placenta
IGg
Habituation
Ability to block out stimuli
Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?
"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Explanation: Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination
A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?
"The bladder will covered in a sterile plastic bag to keep it moist." Explanation: In the preoperative period, the infant care is focused on protecting the exstrophied bladder and preventing infection. The infant is kept in a supine position, and the bladder is kept moist and covered with a sterile plastic bag. Change soiled diapers immediately to prevent contamination of the bladder with feces. Sponge-bathe the infant only rather than immersing him or her in water to prevent pathogens in the bath water from entering the bladder. Consult the ostomy nurse if necessary.
Second period of reactivity
-2 to 8 hrs of life -awakens and shows interest in stimuli -1st stool/void -motor activity -encourage bonding and ask questions
Period of decreased responsiveness
-30 to 120 mins of life -period of sleep or decrease activity -encourage rest/bonding
First period of reactivity
-birth to 30-120 mins after birth -alert/moving -may appear hungry -encourage feeding/bonding
Normal weight range for newborn
2500-4000 grams
Blood Pressure Systolic&Diastolic
50-75 & 30-45
The newborn was just delivered. The nurse observes the following: vigorous crying, heart rate of 150, good muscle flexion, respiratory rate of 50 and acrocyanosis. What will the nurse assign as the 1 minute APGAR score?
9 Rationale:•The APGAR score is 9 because one point was taken off for color. Grimace would receive 2 points for vigorous crying, heart rate would receive 2 points for rate of 150, activity would receive a score of 2 points for good muscle flexion, and respiratory rate would receive 2 points for respirations of 50 breaths/minute.
The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant?
Creases covering two-thirds of the anterior foot Explanation: On the Ballard Scale, an assessment and documentation of a crease covering two-thirds of the anterior foot is interpreted as characteristic of a full-term newborn. The creases are assessed on the foot, not the hand or brow. No creases are indicative of a preterm newborn.
Social behaviors
Cuddling and snuggling with parent
Which finding might be seen in a neonate suspected of having an infection?
Decreased temperature Explanation: A decreased temperature in the neonate may be a sign of infection. The neonate's color commonly changes with an infectious process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next?
Determine the newborn's blood type and rhesus. Explanation: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?
Evaporative Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.
When assessing a preterm newborn, which would the nurse expect to find?
Few palmar creases Rationale:A preterm newborn characteristically has few or no creases on the soles of the feet and palms. Lanugo is abundant, and the skin, although wrinkled, is thin Typically the eyelids are fused.
Newborn Measurements
Head•32cm- 38cm Chest•30cm- 36cm Length•44cm - 55cm
The parent reports that the health care provider said that the infant had a hernia but she can't remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated?
Inguinal hernia Explanation: An inguinal hernia occurs primarily in males and allows the intestine to slip into the inguinal canal, resulting in swelling. If the intestine becomes trapped and circulation is impaired, surgery is indicated within a short period of time.
A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply.
It is thinner and more fragile than an adult's Substances are easily absorbed. Explanation: An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.
A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply.
Lanugo Breast tissue Explanation: When assessing physical maturity for a newborn's gestational age assessment, the nurse would assess lanugo and breast tissue. Posture, arm recoil, and square window are components of the neuromuscular maturity assessment.
A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? A. scarf sign B. square window C. popliteal angle D. Moro reflex
Moro reflex Explanation: There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.
At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the baby's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex?
Moro reflex Explanation: When a baby has a brachial plexus palsy, there will be asymmetry of the Moro reflex. The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. Babinski reflex is a sign of neurologic immaturity.
A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time?
Notify the primary care provider immediately. Explanation: The projectile vomiting should raise suspicions of increasing intracranial pressure and requires emergent intervention, so the nurse should notify the primary care provider immediately. Symptoms of increased intracranial pressure (ICP) may also include irritability, restlessness, personality change, high-pitched cry, ataxia, failure to thrive, seizures, severe headache, changes in level of consciousness, and papilledema. At least every 2 to 4 hours, the nurse should monitor the newborn's level of consciousness, check the pupils for equality and reaction, monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability. Edema and localized redness at the surgical site are potential indications of an infection. Assessing for pain and administering pain medication in this situation can result in the symptoms being masked and the infant could die. Increasing the fluid rate could contribute to the increased volume of fluids in the brain and would exacerbate the situation.
Neuromuscular Maturity
Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear
A newborn is delivered with an estimated gestational age of 36 weeks, measures 2440 grams and measures in the 25th percentile. Select the correct documentation.
Preterm, low birth weight, average for gestational age Rationale:• Anything greater than 20 weeks and under 37 completed weeks is considered preterm, average birth weight is 2500-4000 grams. <2500 grams is defined as low birth weight. Average size for gestational age is between the 10-90 percentile, small for gestational age is <10 percentile.
An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?
Provide oxygen by oxygen hood or ventilator. Explanation: The nurse should administer oxygen to the infant in whatever manner needed to help maintain the infant's oxygen levels. Anticonvulsants are not necessary in treating this disorder. The infant's physical environment should be warm, not cool, and stimulation should be limited for these clients.
Orientation
Response to new environment
The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?
The spinal meninges protrude through the bony defect and form a cystic sac. Explanation: When part of the spinal meninges protrudes through the bony defect and forms a cystic sac, the condition is termed spina bifida with meningocele. In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. A bony defect that occurs without soft-tissue involvement is called spina bifida occulta
Which newborn neuromuscular system adaptation would the nurse not expect to find?
an extrusion reflex at 9 months of age Explanation: An extrusion reflex usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age
Bronchopulmonary dysplasia (BPD) is the result of lung injury in the preterm newborn. What can be done to reduce the incidence of BPD in the preterm newborn?
antepartal administration of steroids to the mother Explanation: BPD can be prevented by administering steroids to the mother in the antepartal period and exogenous surfactant to the newborn to aid in reducing the development of respiratory distress syndrome and its severity. A high oxygen content can cause damage to the neonatal lung. Steroid injections for newborns at risk for BPD do not help the lungs mature. Giving exogenous surfactant to the mother does not increase the level of surfactant in the infant.
While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?
concentration of immature blood vessels Explanation: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns. An allergic reaction would be more generalized and would not be salmon-colored.
A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition?
esophageal atresia Explanation: Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?
first 30 to 60 minutes Explanation: Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.
The Apgar score is based on which 5 parameters?
heart rate, muscle tone, reflex irritability, respiratory effort, and color Explanation: A newborn can receive an Apgar score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.
The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse (PMI)?
lateral to the midclavicular line at the fourth intercostal space Explanation: The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.
Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder?
microcephaly Explanation: Infants with fetal alcohol spectrum disorder are usually born with microcephaly. Their facial features include short, palpebral fissures and a thin upper lip.
A preterm newborn born at 30 weeks' gestation is in the NICU receiving supplemental oxygen. Based on the nurse's understanding of risk reduction for the severity of retinopathy of prematurity (ROP), the nurse monitors the oxygen saturation level, ensuring that the level is within which target range?
mid-80s to lower mid-90s Explanation: Many NICUs have adopted lower oxygen saturations ranges for preterm infants. Oxygen saturation target ranges in the mid-80s to lower mid-90s are usually safe and can reduce the severity of ROP in newborns born at less than 32 weeks' gestation.
Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?
ventricular septal defect Explanation: A ventricular septal defect is the most common intracardiac defect. It consists of an abnormal opening in the septum between the two ventricles
