Chapter 24: Tran
A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority? Complete the Ballard score. Begin resuscitation measures. Review the labor and birth records. Assess the Apgar score again in 5 minutes.
Begin resuscitation measures. Explanation: Determine the Apgar score at 1 and 5 minutes; if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7. The Ballard score would not be performed at this time. Reviewing the L & D records or repeating the Apgar are not priorities.
A nurse makes a home visit to a new mother and her 5-day-old newborn. Assessment of the newborn reveals slight yellowing of the skin on the face and forehead and slowed skin turgor. The mother tells the nurse that she's been having trouble breastfeeding the newborn. "My baby's been feeding about every 4 to 5 hours." Additional assessment reveals about 3 wet diapers per day and 1 to 2 stools per day. Which action by the nurse would be the priority? Call the provider to obtain a prescription for a bilirubin level. Arrange for home phototherapy. Evaluate the mother's technique for breastfeeding. Measure the newborn's abdominal girth.
Call the provider to obtain a prescription for a bilirubin level. Explanation: The assessment findings and report from the mother suggest late-onset breastfeeding jaundice. The nurse should report the findings to the provider and obtain a prescription for a bilirubin level. Once the results are obtained, then the decision for home phototherapy can be made. Although it would be helpful to evaluate the mother's breastfeeding technique to promote enhanced breastfeeding, the priority is to confirm hyperbilirubinemia and institute measures to lower the bilirubin level. Measuring the newborn's abdominal girth would be unnecessary.
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? Acetaminophen Ibuprofen Morphine Aspirin
Morphine Explanation: 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.
Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs? Offer tactile stimulation Provide a dark, quiet environment Play soothing music Incorporate a massage
Provide a dark, quiet environment Explanation: A dark and quiet environment provides relaxation and allows the opportunity for the neonate to withdraw from the alcohol and drugs without becoming overstimulated. Massage and tactile stimulation can stimulate the neonate, leading to seizures. A dark environment is more helpful than soothing music.
The nurse is caring for an intrapartum mother whose fetus has asymmetrical intrauterine growth restriction (IUGR) after the 24th week of gestation. Which nursing action is best? Provide emotional support to the mother and support person as the neonate has anomalies. Regular assessment of the fetal monitor tracings and preparation for a cesarean birth, if needed. Anticipate a precipitous delivery since the neonate is small-for-gestational-age. Use regular assessment techniques as an uncomplicated delivery is anticipated.
Regular assessment of the fetal monitor tracings and preparation for a cesarean birth, if needed. Explanation: The fetus with asymmetrical intrauterine growth restriction is compromised in some manner; thus, regular assessment of the fetal monitor tracings can indicate if the fetus is in distress (a common occurrence). If the fetus is in distress due to the work of birth, be prepared for a cesarean section. Neither a congenital anomaly nor a precipitous delivery is always present with IUGR. Since there is a complication causing IUGR, a complicated delivery is anticipated.
The nurse is caring for a newborn who is large-for-gestational-age (LGA). Which characteristics are documented as a contributing factor? Select all that apply. The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size. The father is obese but mother is of normal weight. The neonate is a female.
The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size. Common contributing factors for a large-for-gestational-age neonate are the mother having a history of previous LGA neonates; the mother having a high glucose level due to a poorly controlled diabetic status; and genetic characteristics of the parents being of a larger size and stature. A larger-sized infant is more correlated with an obese mother than obese father. Males are more likely to be LGA.
The nurse is caring for a preterm neonate and has chosen the following goal: improvement of the neonate's respiratory function. Which expected outcome is most appropriate for the first week? The neonate will not use accessory muscles when breathing. The neonate will have 99% oxygen saturation. The neonate will sleep without apnea periods. The neonate will maintain a temperature under 99.5°F (37.5°C).
The neonate will not use accessory muscles when breathing. Explanation: The goal most appropriate for the first week of life is to not use accessory muscles or grunting when breathing. This signifies an improvement in the respiratory status. A 99% oxygen saturation rate is too high for the neonate. Maintaining the temperature and sleeping without apnea are acceptable goals but not most reflective of improvement in the respiratory status.
As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)? a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus a term female newborn, born vaginally, whose mother has chronic obstructive pulmonary disease the term female newborn, born by a mid-forceps assist, whose mother has hypothyroidism the term male newborn, born by cesarean birth, whose mother has respiratory allergies
a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus Explanation: 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.
A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? maculopapular rash absent Moro reflex greenish stool bronze-colored skin
absent Moro reflex Explanation: An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronze colored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention.
The nurse is assessing a large-for-gestational-age newborn who had shoulder dystocia at birth. Which assessment findings would indicate a possible fracture? absent Moro, bicep, and radial reflexes exaggerated Moro, step, and palmar reflexes absent Moro, radial, and grasp reflexes absent sucking, rooting, and Babinski reflexes
absent Moro, bicep, and radial reflexes Explanation: Common types of birth trauma include a brachial plexus injury seen primarily in large babies or babies with shoulder dystocia. It results from stretching, hemorrhage within a nerve, or tearing of the nerve or the roots associated with cervical cord injury. Erb's palsy is an upper brachial plexus injury evidenced with an absent Moro, bicep, and radial reflex. The grasp reflex is usually present. Klumpke's palsy is manifested by weakness in the hand and wrist; grasp reflex is absent.
A pregnant woman gives birth to a small-for-gestational-age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy? alcohol cocaine heroin methamphetamine
alcohol Explanation: This child's features match those of fetal alcohol spectrum disorder, including microcephaly, small palpebral (eyelid) fissures, abnormally small eyes, and fetal growth restriction.
A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client? application of eye dressings to the infant placing light 6 inches above the newborn's bassinet delay of feeding until bilirubin levels are normal gentle shaking of the baby
application of eye dressings to the infant Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding by either breast milk or formula, therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.
A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems? arterial blood gases chest x-rays echocardiogram angiography
arterial blood gases Explanation: Arterial blood gases are obtained to determine the oxygenation levels and to help differentiate lung disease from heart disease. Chest x-rays will help identify cardiac size, shape, and position. An echocardiogram will evaluate the heart anatomy and flow defects. An angiography will be conducted to prepare the client for cardiac surgery, if needed.
What are the causes of retinopathy of the preterm newborn? Select all that apply. a. insufficient oxygenation in an Isolette b. assistive ventilation with high oxygen content c. fragility of blood vessels in the eyes in response to changes on oxygenation. d. alkalosis e. shock
b. assistive ventilation with high oxygen content c. fragility of blood vessels in the eyes in response to changes on oxygenation. e. shock Retinopathy of the preterm newborn typically develops in both the eyes secondary to an injury such as hyperoxemia resulting from prolonged assistive ventilation and high oxygen exposure, fragility of retinal blood vessels in response to changes in oxygenation, and shock. Alkalosis does not contribute to this problem; acidosis does.
The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: cries when touched. sleeps for long periods of time. weighed above average when born. has facial deformities.
cries when touched. Explanation: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born.
When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? during the first 24 hours of life between 2 and 4 days of life after 5 days postpartum often with formula-fed babies
during the first 24 hours of life Explanation: 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.
The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? high-pitched, shrill cry bile-stained emesis intermittent tachypnea expiratory grunting
expiratory grunting Explanation: 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. Reference:
A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? face trunk legs arms
face Explanation: 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 nurse is caring for a 25-year-old G1P0 at 37 weeks' gestation. The client's history indicates that the client has had alcohol abuse disorder throughout their pregnancy. What signs and symptoms does the nurse expect the newborn to exhibit? Drag words from the choices below to fill in each blank in the following sentence. The nurse recognizes the newborn is exhibiting signs and symptoms of fetal alcohol syndrome, which include
flat midface, thin upper lip, high-pitched, shrill cry, jitteriness Fetal alcohol syndrome (FAS) is caused by intake of alcohol by the pregnant parent during pregnancy; alcohol consumption may be periodic or chronic. Newborns born with FAS have characteristic facial features, are more susceptible to congenital defects, and often have developmental delays. Newborns with FAS have a high-pitched and shrill cry and are generally jittery. Newborns with FAS have a flat midface and a thin upper lip. Newborns with FAS have small and wide-spaced eyes not large narrow-spaced eyes. Newborns with FAS are not easily consoled and have a poor, not an increased appetite.
The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis? frequent yawning and sneezing vigorous rooting and feeding positive Babinski and Moro reflexes cyanotic discoloration of the hands and feet
frequent yawning and sneezing Explanation: Manifestations of neonatal abstinence syndrome include: CNS dysfunction such as hyperactive reflexes resulting in exaggerated Babinski and Moro reflexes; hypertonic muscle tone and constant movement; metabolic, vasomotor, and respiratory disturbances with frequent yawning and sneezing; gastrointestinal dysfunction, including poor feeding; and frantic sucking or rooting. Acrocyanosis is a normal newborn finding which is cyanotic discoloration of the extremities.
The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus? have a serious birth defect grow to an unusually large size suffer from symmetrical intrauterine growth restriction suffer from asymmetrical intrauterine growth restriction
grow to an unusually large size Explanation: Maternal diabetes is the most widely known contributing factor to large-for-gestational-age newborns. LGA babies are frequently born to mothers with diabetes and poor glucose control. Continued high blood glucose levels in the mother lead to an increase in insulin production in the fetus. Increased insulin levels act as a fetal growth hormone causing macrosomia, an unusually large newborn with a birth weight of greater than 4,500 grams (9 pounds, 14 ounces). The incidence of birth defects in newborns born of a mother with gestational diabetes is not greatly increased. IUGR is not a typical outcome of uncontrolled gestational diabetes. It is more likely that the newborn will be large-for-gestational-age.
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? vigorous cry heart rate of 70 beats/min respiratory rate 50 breaths/min pink tongue
heart rate of 70 beats/min Explanation: 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.
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? heroin withdrawal hypoglycemia hypoxia hemolytic disease
hemolytic disease Explanation: 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? above average birth weight large head circumference lethargic and sleepy hyperactive and irritable
hyperactive and irritable Explanation: 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.
What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? tremor activity hyperglycemia jaundice development phenylketonuria
jaundice development Explanation: 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.
By preventing fetal distress during the intrapartum period, which condition is less likely? hemolytic disease of the newborn transient tachypnea of the newborn meconium aspiration syndrome neonatal abstinence syndrome
meconium aspiration syndrome Explanation: A primary cause of meconium aspiration syndrome is fetal distress. Meconium is the thick, pasty, greenish black substance that is present in the fetal bowel. When the fetus releases the meconium in utero, the fetus can inhale the meconium into the lungs. Hemolytic disease of the newborn is caused by blood incompatibility. Transient tachypnea of the newborn is from fluid in the fetal lungs. Neonatal abstinence syndrome is caused by maternal use of drugs or alcohol.
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? choanal atresia diaphragmatic hernia meconium aspiration syndrome pneumonia
meconium aspiration syndrome Explanation: 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.
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? glucose 60 mg/dl (3.3 mmol/l) heart rate 60 beats/min oxygen saturation 98% partial pressure of carbon dioxide (PaCO2) 48 mm Hg
oxygen saturation 98% Explanation: 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.
The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth? cataracts amblyopia nystagmus retinopathy
retinopathy Explanation: Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn. Cataracts is common among older adults and results from the lens becoming opaque. Amblyopia, or lazy eye, is not related to gestational age and is assessed when the child is a toddler. Nystagmus is also not related to gestational age but to neurologic dysfunction of the eye.
Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder? large upper lip short, palpebral fissures wide, palpebral fissures well-developed philtrum
short, palpebral fissures Explanation: Infants with fetal alcohol spectrum disorder are usually born with microcephaly. Their facial features include short, palpebral fissures and a thin upper lip.
Which sign appears early in a neonate with respiratory distress syndrome? bilateral crackles pale gray skin color tachypnea more than 60 breaths/minute poor capillary filling time (3 to 4 seconds)
tachypnea more than 60 breaths/minute Explanation: 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.
Which newborn would the nurse suspect to be most at risk for intellectual disability due to the mother's actions during pregnancy? the child of a client who admits to drinking a liter of alcohol daily during the pregnancy the child of a teenage client who used marijuana through her pregnancy to cope with stress the newborn of a client addicted to heroin and in the methadone maintenance program the newborn of a client who used cocaine occasionally during her pregnancy
the child of a client who admits to drinking a liter of alcohol daily during the pregnancy Explanation: Fetal alcohol spectrum disorder is one of the most common known causes of intellectual disability. The newborn is also at risk for fetal alcohol spectrum disorder and other alcohol-related birth defects. The other illicit drugs are not linked to intellectual disability but have many other teratogenic effects on the fetus/newborn. Marijuana has not shown to have teratogenic effects on the fetus.
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? use of alcohol use of marijuana gestational diabetes positive group B streptococci
use of alcohol Explanation: 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.