High Risk Newborn (Exam 4)

Which finding would alert the nurse to suspect that a newborn has developed NEC? a) bilious vomiting b) clay-colored stools c) sunken abdomen d) irritability

a) bilious vomiting Explanation: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

The nurse caring for newborns on an obstetrical ward assesses an SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) sparse or absent hair b) increased fatty tissue c) tight and moist skin d) poor skin turgor e) diminished muscle tissue f) narrow skull sutures

a) sparse or absent hair d) poor skin turgor e) diminished muscle tissue Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts

Which findings would the nurse expect in a newborn who is considered small for gestational age? Select all that apply. a) sunken abdomen b) increased subcutaneous fat stores c) poor muscle tone over buttocks d) narrow skull sutures e) dry or thin umbilical cord

a) sunken abdomen c) poor muscle tone over buttocks e) dry or thin umbilical cord A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? a) Administer epinephrine. b) Use positive-pressure ventilation. c) Place the newborn's head in a neutral position. d) Hyperextend the newborn's neck.

c) Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings. b) Monitor for signs of hypotonia. c) Perform gentle suctioning. d) Maintain adequate hydration.

a) Administer IV fluids; gavage feedings. The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intravenricular hemorrhage

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) Jaundice within the first 24 hours of life b) Jaundice after the first 24 hours of life c) Negative Coombs' test d) Bleeding from the nose or ear

a) Jaundice within the first 24 hours of life Explanation: 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

When caring for a week-old infant with jaundice, the nurse observes the infant's urine to be dark in color. The nurse would also expect to assess what as indicative of significant hyperbilirubinemia? Select all that apply. a) Poor feeding and lethargy b) Decreased volume of urination c) Light, tan-colored stool after milk intake d) Jaundice limited to the nose, eyes, and ears e) Late passage of meconium stool

a) Poor feeding and lethargy c) Light, tan-colored stool after milk intake e) Late passage of meconium stool Poor feeding and lethargy, late passage of meconium stool, and light, tan-colored stool after milk intake are features of significant hyperbilirubinemia. Decrease in volume of urination is not seen with hyperbilirubinemia. Jaundice limited to the nose, eyes and ears is a physiologic jaundice, and does not indicate significant hyperbilirubinemia

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: a) late preterm. b) preterm. c) postterm. d) term.

a) late preterm. Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy c) pregnancy weight gain of 25 lb (11 kg) d) drug abuse e) hypotension upon admission

a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy d) drug abuse The nurse should be alert to the possibility of an SGA newborn if the history of the mother reveals smoking, chronic medical conditions (such as asthma), and drug abuse. Additional maternal factors that increase the risk for an SGA newborn include hypertension, genetic disorders, and multiple gestations

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? a) ankyloglossia b) esophageal atresia c) torticollis d) talipes

b) esophageal atresia Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? a) hydrocephaly b) flattened maxilla c) bradypnea d) hypoactivity

b) flattened maxilla A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition? a) hypermagnesemia b) hypocalcemia c) hyperkalemia d) hypobilirubinemia

b) hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) high-pitched, shrill cry b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty e) bulging fontanels

b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty The features indicating hypoglycemia in LGA infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak, whimpering cry. High-pitched, shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn? a) closely approximated labia b) shiny heels and palms c) scant coating of vernix d) paper-thin eyelids

b) shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? a) offering a pacifier b) waking the newborn every hour c) checking the newborn's fontanels d) wrapping the newborn snugly in a blanket

b) waking the newborn every hour Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration

A client just gave birth to a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Carry and handle the baby frequently. b) Dress the baby to keep the body warm. c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap.

c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity? a) enhanced ability to digest proteins b) rapid glomerular filtration rate c) fragile cerebral blood vessels d) enlarged respiratory passages

c) fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? a) heparin b) neomycin c) surfactant d) Rho(D) immune globulin

c) surfactant Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? a) "We'll place the lights so that they are about 5 inches above our baby at all times." b) "We should see reddened areas on his skin, which means the treatment is working." c) "We will turn him every ½ hour to make sure that his whole body is exposed." d) "We'll take off the patches on his eyes when we're feeding him so he can look at us."

d) "We'll take off the patches on his eyes when we're feeding him so he can look at us." The lights are to be positioned about 12 to 30 inches above the newborn. The newborn is turned every 2 hours while under the bilirubin lights. Eye patches are removed during feedings so that the newborn can interact with the caregiver. Evidence of effectiveness is indicated by loose, green stools indicating that the bilirubin is being broken down.

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? a) Bronze-colored skin b) Greenish stool c) Maculopapular rash d) Absent Moro reflex

d) Absent Moro reflex An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronzecolored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant? a) The parents will be taught maneuvers to perform on the penis to help straighten it out prior to repairing the urethral opening. b) The infant's penis will not require surgery but may never be completely straight. c) The circumcision may have to be revised when he is older. d) His ability to void and have an erection in adulthood may be impaired and surgery is needed.

d) His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? a) Gaze aversion b) Yawning c) Hiccups d) Quiet, alert state

d) Quiet, alert state When caring for neonates experiencing drug withdrawal, the nurse must be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet, alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate can't handle stimuli at that time

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding? a) A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases. b) This is a normal lab value, and no intervention is needed. c) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels.