High risk Newborn

1,5

A NB in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following s/s is the nurse observing? select all that apply 1. hyperphagia 2. lethargy 3. prolonged periods of sleep 4. hyporeflexia 5. persistent shrill cry

1

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of FAS The nurse should assess this baby for which of the following? 1. poor suck reflex 2. ambiguous genitalia 3. Webbed neck 4. Absent Moro reflex

3 (preterm babies are born with an insufficient supply of adipose tissue that is needed for thermogenesis, or heat generation. The normal temp of a preterm is the same as a full term. There is nothing to explain conduction heat loss)

A 1 day old neonate 32 weeks gestatin is in an overhead warmer. The nurse assesses the morning axillary temp as 96.9. Which of the following could explain this finding? 1. This is a normal temp for a preterm neonate 2. Axillary temps are not valid for preterm babies 3. The supply of brown adipose tissue is incomplete 4. Conduction heat loss is pronounced in the baby

3 (Because the CNS may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate. Kernicterus is the syndrome that develops when a neonate is exposed to high levels of bilirubin over time. The bilirubin cosses the blood brain barrier, often leading to toxic changes in the CNS. The term sequelae refers to the disorders that result after an individual has experienced a disease or injury)

A 6 month old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequela to the illness? 1. BUN and serum creatinine 2. Alkaline phosphatase and bilirubin 3. Hearing testing and vision assessment 4. Peak expiratory flow and blood gas assessment

4 (The indirect Coombs test is performed on the preg woman to detect whether or not she carries antibodies against her fetus's RBC's. The direct Coombs test is performed on the NB cord blood to detect whether or not he or she carries maternal antibodies against his or her blood)

A NB admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1. monitor the baby for jitters 2. Assess the blood glucose level 3. assess the rectal temp 4. monitor the baby for jaundice

2 (bilirubin is excreted thru the bowel. The more the baby consumes the more stools she or he will produce. In the past babies were placed in sunlight to reduce their bilirubin levels, but that is no longer considered safe practice.)

A NB nursery nurse notes that a 36 hr old babys body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. maintain a warm ambient environment 2. have the mother feed the baby frequently 3. have the mother hold the baby skin to skin 4 place the baby naked next to a sunlit window

1,2,5 (oral morphine is given to neonates experiencing severe neonatal abstinence syndrome, to relieve the craving baby has for addicted drug as well as minimizing many of the babys adverse symptoms ie: diarrhea, poor feeding, seizures. other meds that have been administered to affect are methadone, phenobarb, clonidine, buprenophine)

A baby born addicted to cocaine is being given oral morphine. The nurse knows that which of the following are the main reasons for its use? select all 1. contains no alcohol 2. helps to correct diarrhea 3. is nonsedating 4. improves respiratory effort 5. helps to control seizures

2 (Babies born with erythroblastosis fetalis often are in severe congestive heart failure and therefore exhibit anasarca. They are markedly anemic.)

A baby is born with erythroblastosis fetalis. Which of the following s/s would the nurse expect to see? 1. ruddy complexion 2. anasarca 3. alopecia 4. erythema toxicum

1

A baby was born to a mother who recieved no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill high pitched cry. The babys glucose levels are normal. For which of the following should the nurse request an order for from the Dr? 1. Urine tox test 2. biophysical profile test 3. chest and abdominal ultrasound 4. O2 sat and blood gas assessment

1

A baby whose mother was addicted to heroin during pregnancy is in NICU. Which of the following nursing interventions would be appropriate for the nurse to perform? 1. tightly swaddle the baby 2. place the baby prone in the crib 3. provide needed stimulation to the baby 4. feed the baby half-strength formula

1

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the babys eyes with eye pads 2. Turn the lights off for ten minutes every hour 3. clothe the baby in a shirt and diaper only 4. Tightly swaddle the baby in a baby blanket

1 (ABO incompatibility can arise when the mother is type O and the baby is either type A or B. A mother whose blood is type O, the blood type that is antigen neg, will produce anti A or anti B antibodies against blood types A and or B. As a result the baby will become jaundiced)

A babys blood type is B neg. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O neg 2. Type A neg 3. Type B pos 4. Type AB pos

3 (alcohol can irritate punctured skin. The foot should be covered in a warm wrap prior to heel stick. The lateral heel is the site to use. The ankle and foot should be firmly grasped. Dont use the posterior surface of the heel.)

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should then nurse make during the procedure? 1. cover the foot with an iced wrap for one minute prior to the procedure 2. avoid puncturing the lateral heel to prevent damaging sensitive structures 3. allow the site to dry after rubbing it with an alcohol swab 4. firmly grasp the calf of the baby during the procedure to prevent injury

4 (The stools can be very caustic to the delicate skin. The nurse should cleanse the area well and inspect the skin for any sign that the skin is breaking down. Green stools are expected in this situation, due to the increased bilirubin excreted and not relatied to infection)

A neonate under phototherapy for elevated bilirubin levels. The babys stools are now loose and green. Which of the following actions should the nurse take at this time? 1. DC the phototherapy 2. notify the HCP 3. take the babys temp 4. assess the babys skin integrity

2 (assess the glucose levels to determine if hypoglycemic first. The baby IS hypothermic, but the best intervention would be to place the baby under a warmer rather than swaddle. Plus the glucose should be evaluated. Hypothermia does put the baby at risk for hypoglycemia. )

A nurse makes the following observation when admitting a full term breastfeeding infant into the NB nursery: 9lb 2 oz, 21 inches long, TPR: 96.9, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. swaddle the baby to provide warmth 2. assess the glucose levels of the baby 3. take the baby to the mother for feeding 4. administer the neonatal medications

1 (healthy hydrated NB saturate their diapers a minimum of 6 times in 24 hrs)

A nursing diagnoses for a 5 day old NB under phototherapy is :Risk for fluid volume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hrs the baby will: 1. urinate at least 6 times 2. breastfeed 2-4 times 3. lose less than 12% of the babys birth weight 4. have an apical HR of 160-170 bpm

2 (rotating the babies position maximizes the therapeutic response because the more skin surface that is exposed to the light source the better the results are. )

An 18 hr old baby with an elevated bilirubin level is placed under the bili lights. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration 2. Rotate the baby from front to back every 2 h 3. Apply restraints to keep the baby under the light 4. Administer IV fluids via pump per Dr. orders

1 (behavioral characteristics of FAS: weak suck, irritability, tremulousness, and seizures are present at birth)

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of FAS. The nurse should assess this baby for which of the following? 1. poor suck reflex 2. ambiguous genitalia 3. webbed neck 4. absent moro reflex

1 (Babies who are stressed by for example cold, sepsis, or prematurity will often exhibit signs of respiratory distress. Other signs of respiratory distress in the neonate are grunting, tachypnea, asynchronous breathing, and cyanosis. )

Four babies are in the NB nursery The nurse pages the neonatologist to see the baby who exhibits which of the following? 1. intercostal retractions 2. erythema toxicum 3. pseudostrabismus 4. vernix caseosa

4 (Grunting is often accompanied by tachypnea, another sign of resp. distress. Essentially, the bby is producing his or her own positive end expiratory pressure (PEEP) to maximize his or her respiratory function)

The baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the babys mouth 2. Check the babys diaper 3. have the mother feed the baby 4. assess the respiratory rate

3 (Narcan would put the baby into a traumatic withdrawal. Morphine may be admined to an addicted baby to control diarrhea assoc. with neonatal abstinence. Methadone may be admined to neonates with severe neonatal abstinence syndrome. Phenobarb is sometimes administered to control seizures.)

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. morphine 2. methadone 3. narcan 4. phenobarbital

1 (The baby with erythroblastosis fetalis would exhibit signs of sever anemia, which a hct of 24% reflects. )

Which of the following lab findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hct 24% 2. WBC 45,000 3. Na 125 4. K 5.5

3 (postdates are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates. Cold stress syndrome develops from a neonates inability to create heat thru metabolic means. In lieu of food intake, brown adipose tissue and glycogen stores in the liver are the primary substances used for thermogenesis. )

Which of the following neonates is at highest risk for cold stress syndrome? 1. infant of a diabetic mother 2. infant with RH incompatibility 3. postdate neonate 4. Down syndrome neonate

3 (Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea. Glucose of 50 is wnl. Normal blood glucose are lower in neonates than in the older child and adult and acrocyanosis is normal for a neonates first day or two)

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temp of 96.5? 1. blood glucose of 50 2. acrocyanosis 3. tachypnea 4. oxygen saturation of 96%