Chapter 23: Nursing Care of the Newborn With Special Needs (Prep U)
Which finding would the nurse expect to assess in an infant with hypoglycemia? limpness or jitteriness prolonged jaundice pain along the sixth cranial nerve excessive hunger
limpness or jitteriness Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. Avoid coming to work when ill. Initiate universal precautions when caring for the infant. Cover jewelry while washing hands. Avoid using disposable equipment. Use sterile gloves for an invasive procedure.
Avoid coming to work when ill. Use sterile gloves for an invasive procedure. Initiate universal precautions when caring for the infant. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.
A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure? Ensure that the infant is kept warm. Evaluate the infant's urinary output. Assess the infant's cranial vascular tension. Prevent the infant from crying.
Ensure that the infant is kept warm. Preterm infants must be protected from chilling during all procedures, because maintaining warmth is a major concern because of immaturity.
The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation? Infant is crying. Infant is kicking feet. Infant is quiet. Infant has hand in mouth.
Infant has hand in mouth. Self-regulation is a form of self-soothing for an infant, such as sucking on hands or putting hand to mouth.
Documentation of a newborn's weight identifies the newborn as extremely-low-birth-weight. The nurse correlates this information as placing the newborn's weight at which level? Approximately 2,500 g. More than 4,000 g. Less than 1,000 g. At a maximum of 1,500 g.
Less than 1,000 g. An extremely-low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g.
A nurse is assisting with the resuscitation of a preterm newborn. Which assessment would help assist the team in determining that the resuscitation efforts have been successful? weak cry effort respiratory rate of 10 breaths per minute pulse rate of 110 beats per minute pink conjunctiva
pulse rate of 110 beats per minute Resuscitation measures are continued until the newborn has a pulse above 100 bpm, a good healthy cry or good breathing efforts, and a pink tongue. This last sign indicates a good oxygen supply to the brain. Conjunctival assessment would be of no benefit. A respiratory rate of 10 breaths per minute alone does not indicate the respiratory effort.
A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition? hydrocephalus respiratory distress syndrome esophageal atresia Down syndrome
respiratory distress syndrome Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.
The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. pregnancy weight gain of 25 lb (11 kg) hypotension upon admission asthma exacerbations during pregnancy drug use smoking during pregnancy
smoking during pregnancy asthma exacerbations during pregnancy drug use The nurse should be alert to the possibility of an SGA newborn if the history of the mother reveals smoking, chronic medical conditions (such as asthma), and a substance use disorder. Additional maternal factors that increase the risk for an SGA newborn include hypertension, genetic disorders, and multiple gestations.
The nurse determines a newborn is small-for-gestational-age based on which characteristics? wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores wasted appearance of extremities, gelatinous umbilical cord, and abundant subcutaneous fat stores normal subcutaneous fat stores, cord-like umbilical cord, and increased development to extremities reduced subcutaneous fat stores to buttocks, thicker umbilical cord, and smaller head compared to body
wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores The nurse should perform a thorough physical examination of the newborn and closely observe the newborn for typical SGA characteristics, which include the following: a newborn head that is disproportionately large compared with rest of body; a wasted appearance of extremities with reduced subcutaneous fat stores; a reduced amount of breast tissue; poor muscle tone over buttocks and cheeks; and a thin umbilical cord.
Which factor places newborns at risk for ongoing health problems? term birth vaginal birth average weight perinatal asphyxia
perinatal asphyxia Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.
An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse? "Come on over and I will explain your infant's exam and findings." "The infant is okay, just wait until your health care provider speaks to you." "Oh yeah, the infant seems fine, you can see your infant soon." "Wait outside and we will call you later."
"Come on over and I will explain your infant's exam and findings." The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their infant. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response? "Feeding premature infants breast milk establishes the best protective mechanisms." "Yes, as they lack the antibody called IdD that acts as protection from infections." "That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." "Not really, as premature infants are cared for in an isolate, protecting them from infection."
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent handwashing. Breastfeeding will eventually establish some protective mechanisms.
What percentage of neonates require some type of assistance to transition to extrauterine life? 50% 10% 25% 5%
10% Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.
The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? 20th 5th 9th 95th
20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 40 mg/100 ml whole blood 80 mg/100 ml whole blood 100 mg/100 ml whole blood 30 mg/100 ml whole blood
40 mg/100 ml whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 ml whole blood is considered hypoglycemia.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? Begin early feedings either by the breast or bottle. Focus on decreasing blood viscosity by introducing feedings. Place infant on radiant warmer immediately. Give dextrose intravenously before oral feedings.
Begin early feedings either by the breast or bottle. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.
The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance. Closely monitor temperature.
Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with the ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. Discourage contact with parents to maintain asepsis. Take the newborn's temperature often. Give the newborn a warm bath immediately. Dress the newborn in ways to preserve warmth. Supply oxygen for the newborn, if necessary. Handle the newborn as much as possible.
Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? Focus on decreasing blood viscosity by increasing fluid volume. Check blood glucose within 2 hours of birth by reagent test strip. Focus on monitoring and maintaining blood glucose levels. Repeat screening every 2 to 3 hours or before feeds.
Focus on decreasing blood viscosity by increasing fluid volume. The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.
A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. Increase the infant's hydration. Stop breastfeeding until jaundice resolves. Offer early feedings. Initiate phototherapy. Administer vitamin supplements.
Increase the infant's hydration. Offer early feedings. Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.
The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority? Ensure feedings are on demand. Initiate daily newborn weights. Initiate early oral feedings. Monitor the infant at feedings.
Initiate early oral feedings. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL (2.5 mmol/L) necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority.
A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration? Bronchopulmonary dysplasia Retinopathy of prematurity Diminished erythropoiesis Necrotizing enterocolitis
Retinopathy of prematurity Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.
Which newborn would be a priority for the nurse to monitor for thermal regulation difficulties? a preterm newborn who is active, rooting, and has a lusty cry a preterm newborn naked with the mother in skin-to-skin (kangaroo) care a term newborn rooming in with its mother and breastfeeding a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly
a preterm newborn with cyanotic hands, feet, and tongue, feeding poorly A preterm newborn who is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. The other newborns are at risk but not as the priority.
Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. alcohol use renal infection diabetes prepregnancy obesity postdates gestation
diabetes postdates gestation prepregnancy obesity Diabetes, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn being large for gestational age.
At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has occurred when a participant makes which statement? "Appropriate-for-gestational-age describes a newborn with a weight over the 90th percentile at birth." "Infants who are larger-for-gestational-age at birth have fewer complications than the other groups." "Newborns who are appropriate-for-gestational-age at birth have lower chance of complications than others." "Appropriate-for-gestational-age means a newborn is born with a weight that falls in the 10th percentile."
"Newborns who are appropriate-for-gestational-age at birth have lower chance of complications than others." Birth weight variations include appropriate-for-gestational-age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate-for-gestational-age have lower morbidity and mortality than other groups.
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement? "The ability of my amniotic fluid to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my body to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be increased." "The ability of my umbilical cord to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.
A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? Administer vitamin D supplements. Administer 0.5 ml/kg/hr of breast milk enterally. Administer dextrose intravenously. Administer iron supplements.
Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? Place the infant's Isolette near the window so the child can see outside. Keep the environment free of color to reduce eye straining. Provide a mobile the child can see no matter how he or she is turned. Bring the child's open bassinet near the desk area so the infant sees people.
Provide a mobile the child can see no matter how he or she is turned. Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.
An 18-year-old client has given birth at 28 weeks' gestation and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS? Glucocorticoid (GC) is given to the newborn following birth. RDS is caused by a lack of alveolar surfactant. Respiratory symptoms of RDS typically improve within a short period of time. RDS is characterized by heart rates below 50 beats per minute.
RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticoid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen, not improve, within a short period of time after birth. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).
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)? Expiratory lag Deep inspiration Sternal retraction Inspiratory grunt
Sternal retraction The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.
At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate? The infant was born at term but at a low birth weight and small-for-gestational age The infant was a preterm, low-birth-weight and small-for-gestational-age The infant was born at term but at a very low birth weight and small-for-gestational-age The infant was a preterm, very-low-birthweight and small-for-gestational-age
The infant was a preterm, low-birth-weight and small-for-gestational-age Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.
A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment? The infant may have excess of lanugo and vernix caseosa. The newborn may look wrinkled and old at birth. The testes in the child may be undescended. The newborn may have short nails and hair.
The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? The neonate has 7 to 10 mm of breast tissue. The pinna of the ear is soft and flat and stays folded. Creases appear on the interior two-thirds of the sole. The skin is pale, and no vessels show through it.
The pinna of the ear is soft and flat and stays folded. 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.
A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point? Place the infant supine in a radiant heat warmer. Immediately suction the infant's airway. Tip the infant into an upright position. Take a blood sample.
Tip the infant into an upright position. It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold? apnea sleepiness tachycardia crying
apnea A premature neonate has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.
When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? convection radiation conduction evaporation
conduction A conduction heat loss results from direct contact with an object that is cooler.
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: inspiratory "crowing." inspiratory stridor. expiratory wheezing. expiratory grunting.
expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).
What is a consequence of hypothermia in a newborn? skin pink and warm holds breath 25 seconds heart rate of 126 respirations of 46
holds breath 25 seconds 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.
An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant? hypotension hyperglycemia hypoglycemia hypertension
hypoglycemia LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.
A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature? meconium aspiration absence of lanugo increased amounts of vernix hypoglycemia
increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between estimated date of delivery (EDD) and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.
An infant who is diagnosed with meconium aspiration displays which symptom? intercostal and substernal retractions no heart murmur pink skin respirations of 45
intercostal and substernal retractions 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 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? yellow appearance of the newborn's skin tremors, irritability, and high-pitched cry seizures, respiratory distress, cyanosis, and shrill cry meconium aspiration in utero or at birth
meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.
Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process? stained umbilical cord and skin bluish skin discoloration listlessness or lethargy meconium stained fluids followed by tachypnea
meconium stained fluids followed by tachypnea Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.
Which finding is indicative of hypothermia of the preterm neonate? oxygen saturation of 95% regular respirations pink skin nasal flaring
nasal flaring 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 client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? lanugo covering the neonate's body vernix caseosa covering the neonate's body peeling and wrinkling of the neonate's epidermis a sleepy, lethargic neonate
peeling and wrinkling of the neonate's epidermis Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.
The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant? age of 30 years blood group incompatibility grand multiparity placental factors
placental factors Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption (abruptio placentae), malformed and smaller placentas, with placenta previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.
The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings? hypercalcemia polycythemia hyperglycemia hyponatremia
polycythemia Newborns born small for gestational age (SGA) are at risk for polycythemia. They should therefore undergo screening at 2, 12, and 24 hours of age. Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy).
Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? hematocrit of 44% (0.44) respiratory rate of 60 to 70 bpm total bilirubin level of 15 heart rate of 162 bpm
respiratory rate of 60 to 70 bpm The nurse should identify respiratory complications such as tachypnea as a symptom of meconium aspiration in the newborn that results from the presence of meconium in the amniotic fluid. Tachycardia, elevated bilirubin levels, and polycythemia are some of the common problems faced by an SGA newborn, but these are not related to meconium in the amniotic fluid.
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,: the foramen ovale closes prematurely. the ductus arteriosus remains open. the pulmonary artery closes. there are aortic valve strictures.
the ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.
