Evolve Maternal NB

The nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply. Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex

Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply. Bulging fontanels High-pitched crying Apgar score of less than 5 A defect in the lumbosacral area Head circumference 2 cm greater than the chest circumference

1, 2 , 4 An excessive amount of cerebrospinal fluid associated with hydrocephalus causes bulging fontanels. A shrill, high-pitched cry often accompanies progressive hydrocephalus and other neurologic problems. Hydrocephalus complicates approximately 80% of lumbosacral myelomeningoceles. Infants with hydrocephalus may or may not have low Apgar scores. Head circumference 2 cm greater than the chest circumference is expected in a newborn.

A newborn has an intracranial hemorrhage because of a tear in the tentorial membrane sustained during birth. Which clinical finding does the nurse expect the infant to display? Extreme lethargy Weak, timorous cry Generalized purpura Abnormal breathing pattern

Abnormal breathing patterns

An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. What is the nurse's estimate of the infant's age? 2 days 24 hours About 3 to 4 days Less than 24 hours

About 3 to 4 days Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and provides evidence that the mother may have had gonorrhea or a chlamydial infection. The most common presentation of ophthalmia neonatorum occurs by day 3 after birth.

The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed? Heel stick Buccal smear Urinary catheterization Venous blood withdrawal

Buccal smear The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine or venous blood may be used to assess chromosomal aberrations but not definitive for newborn

A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure (CPAP) therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action?

Diminished breath sounds and the PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is receiving oxygen by way of positive pressure. Atelectasis is not expected; if it does occur, it requires immediate attention. Low inspiratory pressure is not the cause of the problem. Slippage of the endotracheal tube is not the cause of the problem.

The nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply. Pneumonia Preterm birth Microcephaly Conjunctivitis Congenital cataracts

1, 2, 4 Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy.

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk for developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. Infection Female sex Prematurity Breast-feeding Formula feeding Maternal diabetes

1, 3, 4, 6 Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Jaundice is more common in male infants. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.

The nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Hypotonia Webbed neck Female sex organs Rocker-bottom feet Widely spaced nipple

2, 3, 5 The broad, webbed neck is an outstanding characteristic of the newborn with Turner syndrome. All infants with Turner syndrome are female because their one sex chromosome is the X chromosome; although they have female sex organs, the organs are underdeveloped, and affected individuals are infertile. Widely spaced nipples are also a characteristic of Turner syndrome. Hypotonia is typical of newborns with Down syndrome and trisomy 18. Rocker-bottom feet are found in infants with trisomy 18.

A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. Crackles Cyanosis Wheezing Tachypnea Retractions

2, 4, 5

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn? Cardiac defect Kidney disorder Diabetes mellitus Esophageal atresia

Esophageal atresia is associated with hydramnios. There is usually a history of polyhydramnios because the fetus in unable to swallow the amniotic fluid. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.

A client who recently gave birth has myasthenia gravis. For which clinical manifestation should the nurse monitor the newborn? Seizures Restlessness Hypoglycemia Feeble limb movements

Feeble lib movements Approximately 10% to 15% of neonates born to women with myasthenia gravis develop neonatal myasthenia. Symptoms include a poor cry, respiratory difficulties, muscle weakness, and poor sucking, a weak Moro reflex and feeble limb movements. These issues usually resolve within 6 weeks of life. Seizure activity is not expected, because myasthenia gravis in the mother does not cause brain damage in the fetus. Hypotonia, not restlessness, is typical of the newborn whose mother has myasthenia gravis. Hypoglycemia is not associated with myasthenia gravis.

What maternal condition would cause the nurse to expect signs of respiratory distress syndrome (RDS) in a neonate? Has type 1 diabetes Has been hypertensive during pregnancy Was preeclamptic during the labor and birth Was a previous abuser of heroin and other opioids

Has type 1 diabetes Infants of mothers with diabetes are at risk for respiratory distress syndrome as a result of delayed synthesis of surfactant caused by a high serum level of insulin. The infant of a mother with hypertension may be small for gestational age but not necessarily preterm and at risk for RDS. Preeclampsia does not predispose the full-term newborn to the development of RDS. The mother's use of heroin or other opioids does not necessarily predispose the newborn to RDS.

The nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? Persistent diarrhea Decreased abdominal circumference Increased amount of residual gastric aspirates Small amount of vomitus after each gastric feeding

Increased amount of residual gastric aspirates An increasing residual volume from earlier feedings without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate, because the cardiac (lower esophageal) sphincter of the stomach is weak.

The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function? Large amounts of urine are excreted. It is the same as in a full-term newborn. Urine is concentrated, with an increased specific gravity. Acid-base and electrolyte balance are adequately maintained.

Large amounts of urine are excreted. The preterm infant has a reduced glomerular filtration rate and reduced ability to concentrate urine or conserve water. The preterm infant usually has a salt and water diuresis in the first 48-72 hours of life. Preterm infants have a restricted tubular capacity to reabsorb sodium and consequently have large amounts of urine excreted. All systems of the preterm neonate are less developed than in the full-term neonate. Urine is very dilute, not concentrated. Fluid and electrolyte balance in a preterm infant is easily upset.

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action? Assessing the infant for signs of pneumonia Securing a prescription for allergy testing of the infant Bathing the infant's eyes with a tepid boric acid solution Teaching the mother to wash her hands before touching the infant

Pneumonia Chlamydia trachomatis is associated with the development of pneumonia in the newborn. Purulent conjunctivitis at this time suggests a Chlamydia infection, not an allergic response. Boric acid solution will not solve this problem; a prescribed antibiotic is required. Teaching the mother to wash her hands before touching the infant would be done eventually; however, the priority is assessing the infant for signs of pneumonia.

A newborn's discharge from the hospital is being delayed because of a rising reticulocyte count. The infant's mother, who is being discharged, asks the nurse why her baby must stay. The nurse's response is based on the understanding that the infant must be observed for what? Bacterial infection Significant jaundice Bleeding tendencies Adequate oxygenation

Significant jaundice A rising reticulocyte count indicates accelerated erythropoietic activity that may reflect increased red blood cell (RBC) destruction; increased RBC destruction increases the bilirubin level, causing jaundice. With an infection the sedimentation rate or white blood cell (WBC) count, not the reticulocyte count, is increased. Although the reticulocyte count may be increased with chronic blood loss, there are no data to indicate that the infant is bleeding. This test does not reflect respiratory function.

A mother who notes that her newborn regurgitates after feedings asks the nurse whether her baby is ill. What information should the nurse consider prior to responding? It is caused by a spasm of the pyloric valve. It is caused by the infant's position after feeding. An underdeveloped cardiac sphincter causes regurgitation. An infant swallows air while sucking, resulting in regurgitation.

The cardiac sphincter of the newborn is not fully developed; if the stomach is too full, the feeding backs up through the sphincter, and the infant regurgitates. A spasm of the pyloric valve is marked by projectile vomiting, not by regurgitation. Basing the answer on the infant's position is too vague; the position is not described. Swallowing air while suckling may cause cramping or colic.

Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. Irritability High-pitched cry Depressed fontanels Decreased urinary output Ineffective feeding behavior

1, 2, 4 Pressure on the cerebral structures influences the central nervous system, resulting in irritability. A high-pitched cry is common in neonates with increased ICP. Ineffective feeding behavior is typical of neonates with increased ICP. The fontanels are bulging, not depressed, with increased ICP. Decreased urinary output is related to dehydration and kidney problems, not increased ICP.