PrepU Chapter26 Silbert-Flagg & Pillitteri

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the neonate is being born. Which intervention should the nurse implement as a result of this finding?

Provide supplemental oxygen and monitor respiratory status Explanation: When the amniotic fluid is stained greenish black, the neonate is at risk for meconium aspiration syndrome (MAS). Treatment for MAS depends on severity, but standard guidelines include supplemental oxygen and close monitoring of respiratory status. Additional treatment depends on the severity of respiratory compromise. The health care provider would determine if additional treatment is needed. The nurse should not administer oxygen under pressure (bag and mask) until the neonate has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the neonate and flicking the sole of the foot are methods of stimulating breathing in a neonate experiencing apnea.

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an enface position Explanation: To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body

An infant who is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions Explanation: Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

A nurse is providing care to a large for gestational age newborn. The newborn's blood glucose level was 32 mg/dL one hour ago. Breast-feeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do next?

Administer intravenous glucose. Explanation: Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. If hypoglycemia persists, then intravenous dextrose may be needed. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next?

Correct response: Encourage frequent feedings Explanation: Symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. Glucose water is not indicated. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

In hyperbilirubinemia, the decrease in bilirubin excretion could be caused by

Correct response: Hypoxia Explanation: In hyperbilirubinemia there is a decrease in the amount of bilirubin excreted from the body. This can be caused by hypoxia, hypothyroidism, breast milk, a bowel obstruction or prematurity.

Which finding is indicative of hypothermia of the preterm neonate?

Correct response: holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

Which finding is indicative of hypothermia of the preterm neonate?

Correct response: nasal flaring Explanation: Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A neonate has an injury to the brachial plexus. Which of the following conditions is a result of a brachial plexus injury?

Erb palsy Explanation: Injury to the brachial plexus results in Erb palsy or a paralysis of the arm caused by injury to the upper group of the arm's main nerves. Bulbar palsy is due to a lesion that impairs function of cranial nerves IX, X, XI, and XII. It is not birth related. Bell palsy causes temporary facial paralysis, sometimes seen when forceps are used to assist the birth. Cerebral palsy is caused by hypoxia brain injury.

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has:A)Fewer visible blood vessels through the skinB)More subcutaneous fat in the neck and abdomenC)Well-developed flexor muscles in the extremitiesD)Greater surface area in proportion to weight

Greater surface area in proportion to weight Explanation: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?

Sternal retraction

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. Explanation: The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

hypoglycemia Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

A preterm infant is born at risk for normochromic, normocytic anemia. Which of the following should the nurse do to help reduce the risk of the infant developing this condition? (Select all that apply.)

• Coordinate blood draws so that they are as few as possible • Delay cord clamping at birth Explanation: Many preterm infants develop a normochromic, normocytic anemia (normal cells, just few in number) which can make infants appear pale and lethargic and anorectic. Excessive blood drawing for electrolyte or blood gas analysis after birth can potentiate the problem. For this reason, it's important to see that blood draws in preterm infants are coordinated to the fewest possible and a record of the blood loss for these tallied. Delaying cord clamping at birth to allow a little more blood from the placenta to enter the infant may also help reduce the development of anemia. Phototherapy is performed to prevent excessively high indirect bilirubin levels. Care should be used when administering IV therapy to preterm infants so as to avoid increasing blood pressure. Indomethacin is used to cause closure of a patent ductus arteriosus. A cranial ultrasound is used to detect whether a hemorrhage has occurred.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

Encourage the parents to touch their preterm newborn. Explanation: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?

term, small-for-gestational-age, and low-birth-weight infant Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).