Chapter 24: Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions
After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia? A.) inhaled surfactant B.) intubation C.) suction of the oropharynx D.) antibiotics
Answer: D.) antibiotics
When caring preoperatively for a neonate with a diagnosed tracheoesophageal fistula, which symptoms are anticipated? Select all that apply. - Heartburn with feedings - Excessive drooling - Cyanosis - Elevated heart rate - Frothing - Bradypnea
Answer: - Excessive drooling - Cyanosis - Elevated heart rate - Frothing Rationale: Symptoms resulting from a diagnosed tracheoesophageal fistula include frothing, excessive drooling, cyanosis from mucus production, an elevated heart rate from anxiety of coughing, and difficulty breathing. Once the tracheoesophageal fistula is diagnosed, no oral feedings will be given. This neonate does not have bradypnea.
The nurse in the nursery is told that a neonate at 32 weeks' gestation has been born. What adjustment in nursing care will the nurse make? Select all that apply. - Have an incubator with oxygen, if needed, ready. - Reposition neonate every 2 hours. - Open IV equipment. - Obtain a gram scale. - Set up an apnea monitor. - Provide a stimulating environment
Answer: - Have an incubator with oxygen, if needed, ready. - Reposition neonate every 2 hours. - Open IV equipment. - Obtain a gram scale. - Set up an apnea monitor. Rationale: The neonate is born at least 5 weeks early. Due to the characteristics of a preterm neonate, nursing care is different. A warmed incubator is used as the neonate has thin skin and little subcutaneous fat. Every effort is made to keep the baby warm. Oxygen is available, if needed. Due to the fragility of the skin, reposition the neonate every 2 hours so that no breakdown occurs. The client typically has an IV as medications are delivered through this route. Also, a vein is opened if needed. Preterm neonates also have difficulty breathing. An apnea monitor with heart rate and oxygen saturation is best. Obtain a gram scale for measurement of accurate output. Limited stimulation is best.
Which nursing actions limit overstimulation of the preterm infant? Select all that apply. - Tap on the isolette before opening the door. - Speak softly to the infant. - Keep lights low in the nursery. - Frequently open the isolette portholes. - Coordinate nursing care.
Answer: - Speak softly to the infant. - Keep lights low in the nursery - Coordinate nursing care. Rationale: It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions. Tapping and opening the isolette portholes can startle the infant.
Which action should nurses advocate to help the nation achieve the 2020 National Health Goals? Select all that apply. - teaching about folic acid supplementation prior to conception - obtaining early prenatal care - providing support after the diagnosis of a fetal disorder - encouraging sonograms at every prenatal visit - initiating oral iron supplementation at the time of conception
Answer: - teaching about folic acid supplementation prior to conception - obtaining early prenatal care - providing support after the diagnosis of a fetal disorder Rationale: Nurses can help achieve the 2020 National Health Goals by urging women to enter pregnancy with an adequate folic acid level, ensuring women obtain prenatal care, and receive comprehensive advice and support after diagnosis of a fetal or newborn disorder. Frequent sonograms are not necessary, and initiating oral iron supplementation at conception may worsen the nausea and vomiting of early pregnancy.
A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement? A.) "All congenital disorders can be diagnosed at birth." B.) "Hydrocephalus may be recognized at birth." C.) "Hydrocephalus may not be diagnosed until after a few weeks or months of life." D.) "Congenital defects may be caused by genetic or environmental factors."
Answer: A.) "All congenital disorders can be diagnosed at birth." Rationale: All congenital disorders are not diagnosed at birth. Hydrocephalus is one such disorder that may be diagnosed at birth but also may not be diagnosed until after a few weeks or months. It is also true that congenital defects may be caused by both genetics and environmental factors.
The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby? A.) "It's a good idea to stop drinking alcohol 3 months before trying to get pregnant." B.) "It's important to add iron and vitamin B supplements to your diet." C.) "It would be good to stop smoking before getting pregnant." D.) "It's important to keep insulin levels controlled during pregnancy."
Answer: A.) "It's a good idea to stop drinking alcohol 3 months before trying to get pregnant." Rationale; Alcohol is one of the many teratogenic substances that cross the placenta to the fetus. Fetal alcohol spectrum disorder is often apparent in newborns of mothers with chronic alcoholism and sometimes appears in newborns whose mothers consume low-to-moderate amounts of alcohol. No amount of alcohol is believed to be safe, and women should stop drinking at least 3 months before they plan to become pregnant. The ability of the mother's liver to detoxify the alcohol is apparently of greater importance than the actual amount consumed. Fetal alcohol spectrum disorder is characterized by low birth weight, smaller height and head circumference, short palpebral fissures (eyelid folds), reduced ocular growth, and a flattened nasal bridge. These newborns are prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia. Their growth continues to be slow, and their mental development is delayed despite expert care and nutrition. Smoking is related to respiratory issues. Proper nutrition and glucose control are also important but do not result in fetal alcohol spectrum disorder.
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? A.) "The bladder will be covered in a sterile plastic bag to keep it moist." B.) "Your baby will be cared for in the prone position with a cover over the bladder." C.) "We will care for the bladder with frequent sterile tub baths to keep it moist." D.) "Disturbances to the bladder with diaper changes will be kept to a minimum."
Answer: A.) "The bladder will be covered in a sterile plastic bag to keep it moist." Rationale: In the preoperative period, 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.
A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate? A.) "The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days." B.) "The tiny blood vessels under your newborn's skull broke during labor and caused the swelling. It will get better in about 2 to 3 weeks." C.) "You must have had some problems during labor with keeping your blood pressure under control. Your newborn will need to be handled gently." D.) "Your newborn has a collection of blood that was caused by tearing of the veins and is pushing on the brain. This collection of blood will need to be drained."
Answer: A.) "The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days." Rationale: Assessment indicates that the newborn has caput succedaneum. This is soft tissue swelling caused by edema of the head against the dilating cervix during the birth process. In caput succedaneum, swelling is not limited by suture lines; it extends across the midline and is associated with head molding. It does not usually cause complications other than a misshapen head and usually resolves over the first few days without treatment. Cephalohematoma is the subperiosteal collection of blood secondary to the rupture of blood vessels between the skull and periosteum. Suture lines delineate its extent and it is usually located on one side, over the parietal bone. Cephalohematoma resolves gradually over 2 to 3 weeks without treatment. Subarachnoid hemorrhage (one of the most common types of intracranial trauma) may be due to hypoxia/ischemia, variations in blood pressure, and the pressure exerted on the head during labor. Bleeding is of venous origin, and underlying contusions also may occur. Subarachnoid hemorrhage requires minimal handling to reduce stress. Subdural hemorrhage (hematomas) involves tears of the major veins or venous sinuses overlying the cerebral hemispheres or cerebellum. Increased pressure on the blood vessels inside the skull leads to tears. Subdural hematoma requires aspiration; can be life-threatening if it is in an inaccessible location and cannot be aspirated.
At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the neonate'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? A.) Moro B.) stepping C.) rooting D.) Babinski
Answer: A.) Moro Rationale: When a neonate has a brachial plexus palsy, there will be asymmetry of the Moro reflex (startle reflex). The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. A positive Babinski sign indicates neurologic immaturity.
A client at 6 weeks' gestation asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? A.) Spinach, oranges, and beans B.) Milk, yogurt, and cheese C.) Bananas, avocados, and coconut D.) Pork, beans, and poultry
Answer: A.) Spinach, oranges, and beans Rationale; Folic acid assists in preventing the incidence of neural tube disorders. These foods include green, leafy vegetables; citrus fruits, beans, and fortified breads; cereals, rice, and pasta. Milk, yogurt, and cheese are high in calcium. Bananas, avocados, and coconut are high in potassium. Pork, beans, and poultry are high in iron.
An infant is born with an omphalocele. Which explanation by the nurse is the best description of the feeding plan for the infant? A.) The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool. B.) The infant will be fed breast milk because it is easier to digest and obtains protective properties. C.) The infant will receive a continuous enteral feeding to maintain bowel activity. D.) The infant will be NPO and given a pacifier to stimulate the sucking reflex.
Answer: A.) The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool. Rationale: The infant is fed by TPN, and no enteral feedings are given, to prevent the bowel from filling with air and stool. Pacifiers are not given because they distend the bowel with air, which makes the surgical repair more difficult.
The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority? A.) The neonate will be free from infection. B.) The neonate will exhibit signs of bonding with parents. C.) The neonate will urinate 2 to 3 ml/kg/hour D.) The neonate will not cry during diapering.
Answer: A.) The neonate will be free from infection. Rationale: The highest priority goal is that the neonate will be free from infection. This neonate has open mucosa of the bladder. In addition, the neonate's urinary tract is developed and leads to the bladder and then the kidneys. Nursing intervention must include frequent vital signs; inspection of the site; observation for drainage, color and clarity of urine in diaper; and frequent urinalysis as ordered until surgical correction. Bonding is always a goal when caring for a neonate and family. Having an adequate urine output is an appropriate goal. Due to the sensitive nature of the mucosa, it is important for the neonate to not experience discomfort, particularly when the area is being cleansed.
Which assessment finding within the first 24 hours of birth requires immediate health care provider notification? A.) The skin is jaundiced. B.) Milia is noted on the nose. C.) The neonate slept for 18 hours. D.) The neonate ate 1 to 2 oz of formula.
Answer: A.) The skin is jaundiced. Rationale: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. This neonate exhibits pathologic jaundice, which needs to be reported immediately. Milia is common on the newborn. It is appropriate for the newborn to sleep for most of the day and eat a couple ounces of formula.
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? A.) a sudden drop in hematocrit B.) soft, flat anterior fontanels (fontanelles) C.) pink skin with noted blue extremities D.) intake and output for 8 hours
Answer: A.) a sudden drop in hematocrit Rationale: The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels (fontanelles), changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.
As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)? A.) a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus B.) a term female newborn, born vaginally, whose mother has chronic obstructive pulmonary disease C.) the term female newborn, born by a mid-forceps assist, whose mother has hypothyroidism D.) the term male newborn, born by cesarean birth, whose mother has respiratory allergies
Answer: A.) a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus Rationale: It is necessary to review the maternal history for risk factors associated with RDS. Risk factors in the term infant placing the infant at most risk include a cesarean birth in the absence of preceding labor, male gender, and maternal diabetes, which produces high levels of insulin that inhibit surfactant production. The other infant situations would not be the priority.
Which measure would the nurse expect to be included in the plan of care for an infant of a mother with diabetes who has a serum calcium level of 6.2 mg/dl (1.55 mmol/l)? A.) administration of calcium gluconate B.) initiation of phototherapy C.) infusions of intravenous glucose D.) initiation of oral feedings
Answer: A.) administration of calcium gluconate Rationale: Serum calcium levels less than 7 mg/dl (1.75 mmol/l) indicate the need for supplementation with oral or IV calcium gluconate. Phototherapy would be used if the infant develops hyperbilirubinemia. Intravenous glucose solutions would be used to stabilize the infant's blood glucose levels and prevent hypoglycemia. Feedings help to control glucose levels, reduce hematocrit, and promote bilirubin excretion.
A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects? A.) alcohol B.) smoking C.) recreational drugs D.) obesity
Answer: A.) alcohol Rationale; Alcohol is now recognized as the leading preventable cause of birth defects and developmental disorders in the United States. Smoking, recreational drugs, and obesity are also contributing factors.
The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis? A.) bloody stools B.) poor suck reflex C.) high-pitched cry D.) meconium stools
Answer: A.) bloody stools Rationale: NEC assessment includes assessing the newborn's health history and physical examination as well as laboratory and diagnostic testing. The onset of NEC is demonstrated by the development of feeding intolerance, abdominal distention, and bloody stools in a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock with RDS, temperature instability, lethargy, hypotension, and oliguria.
The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily? A.) colostomy B.) intravenous fluids C.) nasal cannula for oxygen D.) nasogastric tube
Answer: A.) colostomy Rationale; Surgical intervention is needed for both high and low types of imperforated anus. Surgery for a high type of defect involves a colostomy in the newborn period, with corrective surgery performed in stages to allow for growth. The newborn will require intravenous fluids, nasogastric tube attached to low suction, and oxygen in the immediate postoperative period. Once bowel function has become established, these should no longer be needed.
When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? A.) during the first 24 hours of life B.) between 2 and 4 days of life C.) after 5 days postpartum D.) often with formula-fed babies
Answer: A.) during the first 24 hours of life Rationale: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies.
A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? A.) face B.) trunk C.) legs D.) arms
Answer: A.) face Rationale: Neonatal jaundice first becomes visible in the face and forehead. Identification is aided by pressure on the skin, since blanching reveals the underlying color. Jaundice then gradually becomes visible on the trunk and extremities.
A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication? A.) intraventricular hemorrhage (IVH) B.) cold stress C.) respiratory distress syndrome D.) retinopathy of prematurity (ROP)
Answer: A.) intraventricular hemorrhage (IVH) Rationale: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full or bulging fontanel (fontanelle), cyanosis, and increased head circumference.
The perinatal nurse is assessing a large-for-gestational age infant born by breech birth and notes that the infant is irritable and does not move the right arm. For what would the nurse assess? A.) midclavicular fracture B.) brachial plexus injury C.) phrenic nerve injury D.) cranial nerve trauma
Answer: A.) midclavicular fracture Rationale: Midclavicular fractures most often occur during births of newborns with macrosomia. The newborn is irritable and does not move the arm on the affected side either spontaneously or when the Moro reflex is elicited. A brachial plexus injury usually presents with the extremity adducted and internally rotated with absent shoulder movement. Phrenic nerve palsy is not associated with birth injuries and is caused by lesions along the phrenic nerve. The newborn does not demonstrate signs of cranial nerve trauma, which would be evident in the face.
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? A.) newborn who is type A, mother who is type O B.) newborn who is type A, father who is type O C.) newborn who is type O, mother who is type O D.) newborn who is type O, father who is type A
Answer: A.) newborn who is type A, mother who is type O Rationale: Hemolytic disease of the newborn may develop when a mother and the unborn fetus have different blood types. The disease occurs when the immune system of the mother sees the fetus's red blood cells as foreign. Antibodies then develop against the fetus's red blood cells. These antibodies attack the red blood cells beginning at birth, causing them to break down too early. There is more than one way in which the fetus's blood type may not match the mother's. Commonly, it is the result of ABO incompatibility. It also occurs with Rh factor incompatibility. Of the options provided, the newborn with type A and the mother with type O will result in hemolytic disease of the newborn.
A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome? A.) the male preterm infant born by cesarean birth with cold stress B.) the preterm female infant born vaginally whose mother has asthma C.) the term male infant born vaginally with a positive Babinski sign D.) the term female infant whose mother has hypertension
Answer: A.) the male preterm infant born by cesarean birth with cold stress Rationale: The most common factor is a premature birth with additional factors of cesarean births and cold stress. Vaginal births and a parental history of asthma do not correlate with RDS. A positive Babinski sign is normal in newborns and children up to 2 years old. Maternal hypertension with a term birth as well do not correlate.
A client asks the nurse at a prenatal class about acquired disorders. The nurse correctly responds that an acquired disorder: A.) typically occurs at or soon after birth. B.) may result from problems experienced by the woman after her pregnancy. C.) can be defined as structural or functional or metabolic abnormalities at birth. D.) is very complex, involving many genes and gene products.
Answer: A.) typically occurs at or soon after birth. Rationale: Acquired disorders typically occur at or soon after birth. They may result from problems or conditions experienced by the woman during her pregnancy or at birth, such as diabetes, maternal infection, or a substance use disorder, or conditions associated with labor and birth, such as prolonged rupture of membranes or fetal distress.
A 36-week neonate born weighing 1,800 g has microcephaly and microphthalmia. Based on these findings, which risk factor might be expected in the maternal history? A.) use of alcohol B.) use of marijuana C.) gestational diabetes D.) positive group B streptococci
Answer: A.) use of alcohol Rationale: The most common sign of the effects of alcohol on fetal development is restricted growth in weight, length, and head circumference. Intrauterine growth restriction is not characteristic of marijuana use. Gestational diabetes usually produces large-for-gestational-age neonates. Positive group B streptococcus is not a relevant risk factor.
A nurse is caring for a newborn with asphyxia. Which nursing management is involved when treating a newborn with asphyxia? A.) Ensure adequate tissue perfusion. B.) Ensure effective resuscitation measures. C.) Administer IV fluids. D.) Administer surfactant as prescribed.
Answer: B.) Ensure effective resuscitation measures. Rationale: Ensuring effective resuscitation measures is the nursing intervention involved when treating a newborn for asphyxia. Ensuring adequate tissue perfusion and administering surfactant are nursing interventions involved in the care of newborns with meconium aspiration syndrome. Similarly, administering IV fluids is a nursing intervention involved in the care of newborns with transient tachypnea.
A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? A.) Expose the newborn's skin minimally. B.) Shield the newborn's eyes. C.) Discourage feeding the newborn. D.) Discontinue therapy if stools are loose, green, and frequent.
Answer: B.) Shield the newborn's eyes. Rationale; The nurse should shield the newborn's eyes and cover the genitals to protect these areas from becoming irritated or burned when using direct lights and to ensure exposure of the greatest surface area. The nurse should place the newborn under the lights or on the fiberoptic blanket, exposing as much skin as possible. Breast or bottle feedings should be encouraged every 2 to 3 hours. Loose, green, and frequent stools indicate the presence of unconjugated bilirubin in the feces. This is normal; therefore, there is no need for therapy to be discontinued. Lack of frequent green stools is a cause for concern.
A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred? A.) The infant's mother must have had a long labor. B.) The infant's mother probably had diabetes. C.) The infant may have experienced birth trauma. D.) The infant may have been exposed to alcohol during pregnancy.
Answer: B.) The infant's mother probably had diabetes. Rationale: The nurse should know that the infant's mother more than likely had/has diabetes. The large size of the infant born to a mother with diabetes is secondary to exposure to high levels of maternal glucose crossing the placenta into the fetal circulation. Common problems among infants of mothers with diabetes include macrosomia, respiratory distress syndrome, birth trauma, hypoglycemia, hypocalcemia and hypomagnesemia, polycythemia, hyperbilirubinemia, and congenital anomalies. Listlessness is also a common symptom noted in these infants. Infants born to clients who use alcohol during pregnancy, infants who have experienced birth traumas, or infants whose mothers have had long labors are not known to exhibit these particular characteristics, although these conditions do not produce very positive pregnancy outcomes. Infants with fetal alcohol spectrum disorder or alcohol exposure during pregnancy do not usually have hypoglycemia problems.
The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? A.) The large-for-gestational-age neonate B.) The neonate delivered by cesarean section C.) The neonate whose mother received limited prenatal care D.) The neonate born at 41 weeks' gestation
Answer: B.) The neonate delivered by cesarean section Rationale: While every neonate has the respiratory system assessed, some are at higher risk of complications than others. The neonate born via cesarean section is at highest risk for TTN since this infant did not have the opportunity of having fluid expressed from the lungs as he/she descended down the birth canal. The other options are not in the high-risk category.
The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? A.) This is concerning because the swelling does not cross the newborn's suture lines. B.) This is a cephalohematoma that typically spontaneously resolves without interventions. C.) This newborn has a subarachnoid hemorrhage requiring surgical intervention. D.) The newborn has caput succedaneum that will go away within the first week of life.
Answer: B.) This is a cephalohematoma that typically spontaneously resolves without interventions. Rationale: The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia.
A nurse is caring for a newborn who was diagnosed with an imperforate anus. Assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. Which action by the nurse would be appropriate? A.) give gavage feedings B.) clear the airway C.) suction the throat D.) prepare for endotracheal intubation
Answer: B.) clear the airway Rationale: The newborn is showing signs of esophageal atresia based on the assessment. The nurse would clear the airway and notify the health care provider. Newborns with imperforate anus often have other anomalies including esophageal atresia. With this condition, a gastric tube cannot be inserted beyond a certain point because the esophagus ends in a blind pouch. Therefore gavage feedings would be inappropriate. Although the newborn has copious mucus, suctioning the throat and endotracheal intubation are not warranted. Excess secretions should be removed with a bulb syringe.
A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings? A.) cleft palate B.) esophageal atresia C.) cleft lip D.) coarctation of the aortaA nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?
Answer: B.) esophageal atresia Rationale: Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens, no feedings should be given until the newborn has been examined.
A newborn requires resuscitation secondary to asphyxia. The resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding? A.) vigorous cry B.) heart rate of 70 beats/min C.) respiratory rate 50 breaths/min D.) pink tongue
Answer: B.) heart rate of 70 beats/min Rationale: Resuscitation is continued until the newborn has a heart rate higher than 100 beats/min, a good healthy cry, or good breathing efforts and a pink tongue. This last sign indicates a good oxygen supply to the brain.
A nurse is caring for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused the nurse to suspect this might be present? A.) a difficult second stage of labor B.) hydramnios C.) bleeding at 32 weeks' gestation D.) oligohydramnios
Answer: B.) hydramnios Rationale: Because a fetus swallows amniotic fluid, when there is an obstruction of the esophagus, amniotic fluid accumulates, leading to hydramnios.
When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? A.) hyperalert state B.) jitteriness C.) excessive crying D.) serum glucose level of 60 mg/dl
Answer: B.) jitteriness Rationale; Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Excessive crying isn't found in hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.
A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms? A.) garamycin-resistant bacteria B.) necrotizing enterocolitis C.) rotavirus infection D.) respiratory distress syndrome
Answer: B.) necrotizing enterocolitis Rationale: Observations for the development of NEC in the premature newborn may include feeding intolerance with abdominal distention, abdominal tenderness, and bloody or hemoccult-positive stools. Diarrhea is present with NEC and worsening of respiratory distress. Decreased or absent bowel sounds are noted. Rotavirus causes inflammation of a child's stomach and digestive tract, usually triggering vomiting, diarrhea, and fever and not seen in a preterm infant. Garamycin-resistant bacteria is usually seen in older adults.
Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder? A.) large upper lip B.) short, palpebral fissures C.) wide, palpebral fissures D.) well-developed philtrum
Answer: B.) short, palpebral fissures Rationale; Infants with fetal alcohol spectrum disorder are usually born with microcephaly. Their facial features include short, palpebral fissures and a thin upper lip.
Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse? A.) "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks." B.) "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar." C.) "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." D.) "Some women don't have any problem giving birth to large babies. You might want to get a second opinion."
Answer: C.) "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress." Rationale: Transient tachypnea of the newborn (TTN) involves the development of mild respiratory distress in a newborn. TTN results from a delay in absorption of fetal lung fluid after birth. As the fetus passes through the birth canal during birth, some of the fluid is expelled as the thoracic area is compressed. TTN is commonly seen in newborns born by cesarean birth. It typically occurs after birth with the greatest degree of distress occurring approximately 36 hours after birth. TTN commonly disappears spontaneously around the third day.
The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks' gestation? A.) 40 weeks B.) 41 weeks C.) 42 weeks D.) 44 weeks
Answer: C.) 42 weeks Rationale: The nurse is most correct to state that mothers do not progress longer than 42 weeks gestation. At that point, either a cesarean section or an induction would be completed. Actual dates do vary depending on the status of the fetus.
When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? A.) Acetaminophen B.) Ibuprofen C.) Morphine D.) Aspirin
Answer: C.) Morphine Rationale: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid, is given to the client to ease the withdrawal symptoms and also gradually remove opioids from the system. The other options do not ease withdrawal symptoms.
A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn? A.) Document the amount and color of esophageal drainage. B.) Administer antibiotics and total parenteral nutrition as prescribed. C.) Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction. D.) Provide NG feedings only.
Answer: C.) Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction. Rationale: The preoperative nursing care focuses on preventing aspiration by elevating the head of the bed and inserting an NG tube to low suction to prevent aspiration. Documenting the amount and color of drainage is not needed with the NG tube in place. An infant with esophageal atresia is NPO and fed nothing until after the defect is repaired. Administering antibiotics and total parenteral nutrition is a postoperative nursing intervention when caring for a newborn with esophageal atresia.
The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort? A.) Administer benzodiazepines B.) Provide 1 ounce of formula C.) Swaddle and decrease stimulation D.) Promote parental bonding
Answer: C.) Swaddle and decrease stimulation Rationale: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.
Which congenital condition is an immediate emergency requiring notification of the health care provider? A.) Hypospadias B.) Cleft palate C.) Tracheoesophageal fistula D.) Atrial septal defect
Answer: C.) Tracheoesophageal fistula Rationale: The congenital condition which is a medical emergency is a tracheoesophageal fistula. This condition can lead to respiratory distress and pneumonitis. Hypospadias is the urethra opening terminating on the ventral surface of the penis, instead of the tip. Cleft palate is the opening in the roof of the mouth. An atrial septal defect is an opening between the right and left atrial. Hypospadias, cleft palate, and an atrial septal defect may be surgically repaired but are not immediate emergencies.
What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? A.) tremor activity B.) hyperglycemia C.) jaundice development D.) phenylketonuria
Answer: C.) jaundice development Rationale: A direct Coombs test is done to identify hemolytic disease of the newborn; positive results indicate that the newborn's red blood cells have been coated with antibodies and thus are sensitized. The Coombs test is frequently used in the evaluation of a jaundiced infant. Phenylketonuria (PKU) is a genetic disorder in which the body cannot process part of a protein called phenylalanine.
A nurse caring for a client in premature labor knows that the best indicator of fetal lung maturity is which data? A.) meconium in the amniotic fluid B.) glucocorticoid treatment just before delivery C.) lecithin to sphingomyelin ratio of more than 2:1 D.) Absence of phosphatidylglycerol in amniotic fluid
Answer: C.) lecithin to sphingomyelin ratio of more than 2:1 Rationale: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks, and sphingomyelin concentrations remain stable. Meconium is released due to fetal stress before delivery, but it's chronic fetal stress that matures lungs. Glucocorticoids must be given at least 48 hours before delivery. The presence of phosphatidylglycerol indicates lung maturity.
A nurse is caring for a newborn whose chest X-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. For which dangerous condition should the nurse prepare when providing care to this newborn? A.) choanal atresia B.) diaphragmatic hernia C.) meconium aspiration syndrome D.) pneumonia
Answer: C.) meconium aspiration syndrome Rationale: The nurse should assess for meconium aspiration syndrome in the newborn. Meconium aspiration involves patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis that can be seen through chest X-rays. Direct visualization of the vocal cords for meconium staining using a laryngoscope can confirm aspiration. Lung auscultation typically reveals coarse crackles and rhonchi. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Newborns with choanal atresia, diaphragmatic hernia, and pneumonia do not exhibit these manifestations.
The use of breast milk for premature neonates helps prevent which condition? A.) Down syndrome B.) infantile respiratory distress syndrome C.) necrotizing enterocolitis D.) Turner syndrome
Answer: C.) necrotizing enterocolitis Rationale; Components specific to breast milk have been shown to lower the incidence of necrotizing enterocolitis in premature neonates. Infantile respiratory distress syndrome isn't directly influenced by breast milk or breastfeeding. Down syndrome and Turner syndrome are genetic defects and aren't influenced by breast milk.
A newborn, born at 33 weeks' gestation, is on a ventilator in the neonatal intensive care unit (NICU). The newborn receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy? A.) glucose 60 mg/dl (3.3 mmol/l) B.) heart rate 60 beats/min C.) oxygen saturation 98% D.) partial pressure of carbon dioxide (PaCO2) 48 mm Hg
Answer: C.) oxygen saturation 98% Rationale; Rescue treatment is indicated for newborns with established respiratory distress syndrome who require mechanical ventilation and supplemental oxygen. The earlier the surfactant is administered, the better the effect on gas exchange with an aim to have the oxygen saturation level of 98%. Glucose level assessment does not correlate with this therapy. The heart rate of 60 beats/min is an abnormal finding and not a positive result of the therapy. The PaCO2 greater than 45 mm Hg indicates respiratory acidosis. The normal value should be from 35 to 45 mm Hg.
When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding? A.) respiratory distress occurring by 6 hours of age B.) slightly diminished breath sounds C.) see-saw respirations D.) peripheral cyanosis
Answer: C.) see-saw respirations Rationale: Typically the newborn with RDS demonstrates signs and symptoms of severe respiratory distress at birth or within a few hours of birth. Fine, inspiratory crackles are noted on auscultation of a newborn with RDS. See-saw respirations are characteristic of RDS. A newborn with RDS typically demonstrates generalized cyanosis.
Which sign appears early in a neonate with respiratory distress syndrome? A.) bilateral crackles B.) pale gray skin color C.) tachypnea more than 60 breaths/minute D.) poor capillary filling time (3 to 4 seconds)
Answer: C.) tachypnea more than 60 breaths/minute Rationale: Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. Crackles occur as the respiratory distress progressively worsens. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen.
The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement? A.) "A glass of wine with my dinner is OK." B.) "A few cocktails help me relax after a long workday." C.) "Alcoholic drinks stimulate my appetite to eat more." D.) "Alcohol use could cause my baby to be intellectually disabled."
Answer: D.) "Alcohol use could cause my baby to be intellectually disabled." Rationale: Disorders included in the grouping fetal alcohol spectrum disorders are alcohol-related neurodevelopmental disorders (ARND). Children with ARND primarily display intellectual disabilities related to behavior and learning. fetal alcohol spectrum disorder is one of the most common known causes of intellectual disability. Nurses should counsel girls and women to avoid any alcohol use during pregnancy. Nurses can also participate in programs for at-risk groups, including adolescents, especially programs about the serious effects of substance use disorder, especially alcohol use disorder, during pregnancy.
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? A.) Encourage the parents to hold the infant for bonding. B.) Place the infant in a cool environment to prevent overheating. C.) Administer anticonvulsants as prescribed. D.) Provide oxygen by oxygen hood or ventilator.
Answer: D.) Provide oxygen by oxygen hood or ventilator. Rationale: 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.
The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately? A.) Bright red blood from the mouth B.) Bradycardia C.) Vomiting D.) Severe cyanosis
Answer: D.) Severe cyanosis Rationale; Esophageal atresia is the absence of a normal esophageal passage from the pharynx to the stomach, which results in fluids and mucus spilling into the lungs. This can lead to respiratory distress manifested by excessive drooling and periods of respiratory distress with choking and cyanosis. No feeding should be given until the newborn has been examined. If feeding is attempted, the newborn chokes, coughs, and regurgitates; becomes deeply cyanotic; and appears to be in severe respiratory distress. Bright red blood from the mouth is not an indication of esophageal atresia. Bradycardia and vomiting are not signs of respiratory distress.
The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations? A.) Help the child to understand his or her limitations. B.) Keep the family informed about new and effective treatments. C.) Model good medical practices for the child's family. D.) Use reflective listening with nonjudgmental support.
Answer: D.) Use reflective listening with nonjudgmental support. Rationale: Families are naturally apprehensive and find it difficult not to overprotect a child who is ill. They often increase the child's anxiety and cause fear in the child about participating in normal activities. Children are rather sensible about finding their own limitations and usually limit their activities to their capacity if they are not made unduly apprehensive. Some families can adjust well and provide guidance and security for the sick child. Others may become confused and frightened and show hostility, disinterest, or neglect; these families need guidance and counseling. The nurse has a great responsibility to support the family. The nurse's primary goal is to reduce anxiety in the child and family. This goal may be accomplished through open communication and ongoing contact.
When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately? A.) decrease in abdominal girth B.) stools negative for blood C.) bowel sounds in all four quadrants D.) abdomen appearing red and shiny
Answer: D.) abdomen appearing red and shiny Rationale; An abdomen that appears red and shiny in a newborn with NEC indicates peritonitis and must be reported immediately. A decrease in abdominal girth, stools negative for blood, and active bowel sounds suggest that the condition is resolving.
The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? A.) high-pitched, shrill cry B.) bile-stained emesis C.) intermittent tachypnea D.) expiratory grunting
Answer: D.) expiratory grunting Rationale: Expiratory grunting, a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression from mild-to-severe respiratory distress, intercostal retractions, cyanosis, surfactant dysfunction, airway obstruction, hypoxia, and chemical pneumonitis with inflammation of pulmonary tissues are seen in a newborn with meconium aspiration syndrome. A high-pitched cry may be noted in periventricular hemorrhage/intraventricular hemorrhage. Bile-stained emesis occurs in necrotizing enterocolitis. Intermittent tachypnea can be indicative of transient tachypnea of the newborn or any mild respiratory distress problem.
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? A.) heroin withdrawal B.) hypoglycemia C.) hypoxia D.) hemolytic disease
Answer: D.) hemolytic disease Rationale: Any infant admitted to the newborn nursery should be examined for jaundice during the first 36 hours or more. Early development of jaundice (within the first 24 hours) is a probable indication of hemolytic disease. Heroin withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. The hypoglycemic newborn's blood glucose would be low, and a newborn with hypoxia would show signs of respiratory distress.
The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment? A.) above average birth weight B.) large head circumference C.) lethargic and sleepy D.) hyperactive and irritable
Answer: D.) hyperactive and irritable Rationale: The newborn that is withdrawing from alcohol typically is hyperactive, irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of fetal alcohol spectrum disorder include low birth weight, and small height and head circumference. This newborn is prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia.
A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate? A.) negative Coombs test B.) bleeding from the nose or ear C.) jaundice after the first 24 hours of life D.) jaundice within the first 24 hours of life
Answer: D.) jaundice within the first 24 hours of life Rationale; The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life. The neonate would have a positive Coombs test result. Jaundice after the first 24 hours of life is physiologic jaundice. Bleeding from the nose and ear should be investigated for possible causes but probably isn't related to ABO incompatibility.
