Evolve: Maternity - Newborn
The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?
Most important is the institution of a corrective formula soon after birth.
A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?
Preterm
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?
Protecting the sac with moist sterile gauze
What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?
Respiratory distress
What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old?
Screening for phenylketonuria
A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?
"The swelling and discharge are expected. They're a response to your hormones."
The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?
"This is the time when the baby is likely to be most responsive to you."
A newborn male is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do?
Apply the diaper loosely for several days
How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment?
Asymmetry of the gluteal folds
While observing a newborn with a diaphragmatic hernia, what does the nurse expect to identify?
Barrel-shaped chest
A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?
Color
The health care provider hands a neonate to a nurse immediately after birth. What should the nurse do next for the newborn?
Dry and provide skin-to-skin contact with the mother -The priority is preventing heat loss; drying the newborn prevents heat loss through evaporation, and skin-to-skin contact with the mother provides a warm environment while promoting attachment.
An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?
Fever accompanied by decreased responsiveness
Absence or weakness of which of the following reflexes during the newborn assessment should the nurse report to the health care provider?
Gag
What should the nurse do to enhance a neonate's behavioral development?
Help the parents stimulate their awake baby through touch, sound, and sight
On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next?
Suggest that she hold her baby upright for 30 minutes after feeding
A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?
Supporting the parents
A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse?
"Please go on to see your daughter. I'll bring the baby to her room."
A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?
By suctioning the mouth before the nostrils
A nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight?
Placing the naked infant on the scale
When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take?
Having the visitor step outside the room
A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? (Select all that apply.)
2 Cyanosis 4 Tachypnea 5 Retractions -Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.
What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area?
Leave the area untouched or clean with soap and water, then pat it dry.
A nurse is estimating a newborn's gestational age. What parameters should the nurse evaluate? (Select all that apply.)
3 Breast size 5 Genital development
While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because:
It contains exposed tissue and blood
A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?
A demonstration and explanation of infant care
A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents?
A reflex that is expected in the healthy newborn
A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?
Identifying the infant, assessing respirations, and keeping him warm
Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:
Immature liver function
A nurse elicits the Babinski reflex on a newborn. The nurse concludes that this finding indicates:
Immaturity of the central nervous system (CNS)
Which sign indicates to the nurse that a neonate is preterm?
Numerous superficial veins
Vitamin K (Aquamephyton) is to be given to a newborn to aid clotting. Click on the area where the injection will be administered.
The reason for using the vastus lateralis is that the site does not contain major nerves or blood vessels. Other sites, such as the ventrogluteal, which is not used until a child has been walking for 1 year, carry risks. The vastus lateralis muscle, middle third, is the site of choice. Either leg may be used.
A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond?
"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant?
"Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."
While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?
"Infants' feet appear flat because the arch is covered with a fat pad."
One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?
8
On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:
Breakdown of fetal red blood cells
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?
Breaks down the bilirubin into a conjugated form
A nurse is assessing a newborn. Which sign should the nurse report?
Breathing pattern with recurrent sternal retractions
An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?
Bulging fontanels -After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge.
The nurse visualizes and palpates a generalized, soft, edematous area of the scalp on the occiput of a newborn. What does the nurse suspect?
Caput succedaneum
While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?
"This is expected. Your baby is trying to focus."
A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?
"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.)
1 Sneezing 2 Hyperactivity 3 High-pitched cry
A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent:
Cognitive Impairment
What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?
Use tactile stimuli on the chest or extremities
An infant is born in the breech position and diagnosed with Erb palsy (Erb-Duchenne paralysis). What clinical manifestation supports this conclusion?
Flaccid arm with the elbow extended on the affected side
What does the nurse conclude is related directly to an infant's survival in the neonatal period?
Gestational age and birth weight
A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?
Getting an informed consent signed by the mother of the baby
A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:
Has type 1 diabetes -Infants of diabetic mothers are at risk for respiratory distress syndrome as a result of delayed synthesis of surfactant caused by a high serum level of insulin.
A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?
Having sex with many partners
A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate establishes a list of objectives for the infant. What objective should receive the highest priority?
Maintain respirations
What does the nursing care for an infant with necrotizing enterocolitis (NEC) include?
Measuring abdominal girth every 2 hours
A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:
Metabolism of brown fat
What is the most appropriate way for the nurse to elicit the Moro reflex in an infant?
Striking the surface of the infant's crib
After being shown to the parents, a preterm male newborn weighing 3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit. What should the nurse's plan for parental visits include?
Taking them to visit their son as soon as possible
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
Testing for congenital syphilis
What should the nurse's initial discussion include to best help new parents understand tA nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include? he unique characteristics of a newborn?
Expected movements and behaviors
What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate?
They have a tendency to collapse with each breath
New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond?
"Let's talk about it, because there are advantages and disadvantages."
During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?
"Let's talk about why you don't want the medicine to be put into your baby's eyes."
What type of respirations does the nurse expect to identify in a healthy newborn?
Abdominal and irregular
What does an Apgar score recorded 5 minutes after birth help the nurse evaluate?
Adequacy of the transition to extrauterine life
A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?
An audible click on abduction
Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals:
An increased Paco 2 of 55 mm Hg
A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication?
An injury to the brachial plexus during birth
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
Applying sterile, moist nonadherent dressings to the sac
An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate?
Appropriate for gestational age (AGA) and term
The nurse is caring for a client who has a newborn with a neurological impairment. What is the most important nursing action?
Assisting the client with the grieving process
A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range?
Irregular, abdominal, 30 to 60/min -The expected breathing pattern is abdominal and irregular in rhythm and depth (alternating between shallow and deep); the expected rate ranges from 30 to 60 breaths/min.Newborns' respirations are irregular and abdominal.
A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding?
LGA and preterm
The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that:
These areas usually are normal and will fade within the first year.
Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). 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. How should the nurse interpret these data?
These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately.
During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?
Three vessels: one vein and two arteries
The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that:
Crosses the suture line
A newborn whose mother has type 1 diabetes is receiving a continuous infusion of fluids with glucose. What should the nurse do when preparing to discontinue the IV?
Decrease the rate slowly
A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge?
How to monitor their child for signs of jaundice
A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent?
Ophthalmia neonatorum
A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:
Promote clotting of the blood
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
Promote the synthesis of prothrombin
The nurse is to collect a blood sample for glucose testing from the infant of a diabetic mother. The previous sample revealed a level of 38 mg/dL. Mark the area that is safe for the heelstick.
The center of the heel must be avoided because of the presence of the plantar artery. The heelstick must be done because the previous blood glucose level, which was under 40, is indicative of hypoglycemia.
The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast?
The mouth covers most of the areolar surface. -Parents need support and reassurance that their newborn is not permanently damaged. Cephalohematomas do not cause impaired neurological function
A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?
The ribcage is not compressed, then released during birth.
A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?
This reflexive response is an expected part of development.
A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?
By asking her to describe her concerns more fully
The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response?
"The health care provider will tell you how your baby's pain will be controlled."
A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?
"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."
The parents of a newborn tell the nurse that they do not want their infant's eyes treated with a prophylactic agent. How should the nurse respond?
"You'll have to sign an informed consent to refuse the treatment."
Vitamin K 0.5 mg is prescribed for a newborn. The vial on hand is labeled "1 mL = 2 mg." How many milliliters should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL
0.25
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.)
1 Cracked and peeling skin 2 Long scalp hair and fingernails 5 Creases covering the neonate's full soles and palms
At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.)
1 Long nails 2 Wrinkled skin
A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?
A newborn's intestinal tract does not synthesize it for several days after birth.
Which observations are suggestive of postmaturity in a newborn male? (Select all that apply.)
1 Profuse scalp hair 2 Parchmentlike skin 5 Creases covering the entire soles
After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.)
1 Reflex irritability: cry 2 Respiratory rate: good cry 3 Heart rate: 110 beats/min
One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Record your answer using a whole number. ___
8
A nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify?
Tonic neck
A male born at 28 weeks' gestation weighs 2 lb 12 oz. What characteristic does the nurse expect to observe?
Transparent red skin
What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?
Warming the newborn
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine?
Serum glucose level
During assessment of a newborn, a practitioner diagnoses cephalhematoma and informs the parents. The mother asks why her baby's head looks different. What does the nurse take into consideration before responding in terms that the mother will understand?
Swelling that is confined to one part of the scalp is caused by hemorrhage beneath the periosteum.
A new mother asks the nurse whether she may wash her baby in a tub after they go home. What is the nurse's best response?
"Babies can be bathed in a tub after the cord has fallen off."
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse?
"This antibiotic helps keep babies from contracting eye infections."
What clinical findings does the nurse expect to observe in a newborn with trisomy 21 (Down syndrome)? (Select all that apply.)
3 Protruding tongue 4 Hypotonic muscle tone 6 Broad nose with a depressed bridge
Which parts of a newborn's body are usually affected by the rash erythema toxicum neonatorum? Select all that apply.
A face D trunk E buttocks
Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents?
Mucous membranes of the mouth
When calculating an Apgar score for a newborn, what is given a score in addition to the heart rate?
Muscle tone
A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight?
Perform serial glucose readings
A nurse takes into consideration that the effect PKU has on the infant's development will depend on:
Adherence to a corrective diet instituted early
In specific situations gloves are used to handle newborns whether or not they are HIV positive. When is it unnecessary for the nurse to wear gloves while caring for a newborn?
Offering a feeding
A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?
Staying with her after bringing the infant to help her verbalize her feelings.
A newborn with a severe bilateral cleft lip and palate is shown to the father first. The father says, "How could this happen to us? What's my wife going to do? It would've been better if she'd never gotten pregnant." How should the nurse respond?
"This must be very hard on you. I can go with you when your wife sees the baby."
Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby cries all the time, and I don't know what to do." What question should the nurse ask before planning nursing care?
"What is the baby's daily schedule?"
A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.)
2 Foramen ovale 4 Ductus arteriosus
A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?
30 to 60 breaths/min
Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?
5 -According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen. Topics
A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause?
ABO incompatibility
A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?
Chlamydia trachomatis infection
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?
Buccal smear
A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?
Continue to monitor the blood glucose level per policy. -A reading of 48 mg/dL is within the expected blood glucose range for a neonate (40-60 mg/dL) and requires no measures other than continued monitoring for the next 24 hours. Heel sticks are adequate for monitoring the blood glucose level of a neonate
In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?
Documenting an intact reflex
During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter?
Early parenting behavior
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?
Evaporation
A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?
Gastric acidity is low and does not provide bacteriostatic protection.
A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?
Inborn error of metabolism
A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn?
Infection
Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?
Injury to brachial plexus during birth
A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate?
Intrauterine growth restriction (IUGR)
What does the nurse do to elicit the Moro reflex during a newborn assessment?
Jars the infant's bassinet suddenly but gently -Sudden movement causes the startle response (Moro reflex), which begins with extension and abduction of the extremities with a C shape formed by the index finger and thumb, followed by flexion and adduction of extremities and ending with return of the arms to a relaxed position
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?
Jaundice that develops in the first 12 to 24 hours
How does the nurse provide kangaroo care to a preterm infant?
Keep the newborn in skin-to-skin contact with the parent.
What nursing care is most important for a newborn with respiratory distress syndrome (RDS)?
Keeping the infant in a warm environment
A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:
Lack the subcutaneous fat that usually provides insulation
What should the nurse discuss with new parents to help them prepare for infant care?
Learning specific behaviors involving states of wakefulness to promote positive interactions
A newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What should the nurse do?
Notify the practitioner, because circumoral pallor may indicate cardiac problems
A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility?
O
A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture?
Outer heel
Why is it important for the nurse to know the infant's gestational age and how it compares with the birthweight?
Potential problems may be identified.
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?
Remove secretions from the pharynx
In her 36th week of gestation, a client with type 1 diabetes has a 9-lb 10-oz infant in a cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother?
Respiratory distress syndrome
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent?
Retinopathy of prematurity
A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?
Rubella -Congenital rubella (German measles) syndrome results in abnormalities that vary, depending on the gestational age of the fetus when the maternal infection was contracted; the most severe results occur if the mother was infected during the first trimester, when organogenesis is taking place
Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice?
The physiological destruction of fetal red blood cells -After birth, fetal erythrocytes hemolyze, releasing into the circulation bilirubin , which the immature liver cannot metabolize as rapidly as it is produced, resulting in physiological jaundice.
A preterm infant is started on digoxin (Lanoxin) and furosemide (Lasix) for persistent patent ductus arteriosus. Which clinical finding provides the best indication of the effectiveness of the furosemide?
Urine output exceeds fluid intake.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy?
Using shields on the eyes to protect them from the light
After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond?
"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."
The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion?
"Recovery usually occurs in about 3 months."
On her first postpartum day, a client asks the nurse whether her baby has had a test for phenylketonuria (PKU) yet. How should the nurse reply?
"The test won't be done until your baby has had enough milk for the results to be accurate." -The PKU test cannot be done until the newborn has ingested a high-phenylalanine (formula or breast milk) diet for at least 24 hours.
A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?
2. 3 -A heart rate of less than 100 beats/min = 1; slow and irregular respirations = 1; grimaces in response to suctioning = 1; flaccid muscle tone = 0; and cyanosis = 0. This infant's Apgar score is 3. A score of 2 is too low. A score of 4 is too high, as is a score of 5.
At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 breaths/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. What Apgar score should the nurse assign?
8
Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:
Chlamydia and gonorrhea
A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?
Decreased blood pH
A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?
Document the stool in the infant's record
Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?
Enlarged head
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. What condition of the newborn is associated with hydramnios?
Esophageal atresia
A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?
Hypoglycemia
After a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent?
Metabolic acidosis
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:
Milia -Milia are common, are not indicative of illness, and eventually disappear. Lanugo is fine, downy hair.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?
Suctioning the airway
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?
Suctioning the mouth
Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?
Verifying oxygen saturation frequently to adjust flow on the basis of need
While observing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?
Warm the environment -Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact.
The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?
The cause is an increased intravascular pressure during birth.
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)
1 Thin upper lip 3 Small upturned nose 5 Smooth vertical ridge in the upper lip
A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? (Select all that apply.)
3 Deafness 5 Cardiac anomalies
What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?
Barely visible areolae and nipples -Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant at 40 to 42 weeks' gestation.
How should the nurse assess a newborn's grasp reflex?
By pressing the examining fingers against the palms of the newborn's hands
During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition?
Cephalhematoma
A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate?
Clean the penis with warm water at each diaper change.
A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss?
Imbalance between nutrient intake and fluid loss
A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? (Select all that apply.)
1 Pneumonia 2 Preterm birth 4 Conjunctivitis
A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? (Select all that apply.)
1 Preterm infant 3 Small-for-gestational-age infant 4 Large-for-gestational-age infant
An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7 and 9. What nursing actions will be performed on the infant's admission to the nursery? (Select all that apply.)
1 Recording of vital signs 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable
Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.)
1 Small breast buds 2 Wrinkled thin skin 5 Pinnae that remain flat when folded
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented?
Mongolian spots -Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time.
