Maternity & Peds Unit 4 ch 12-14

While collecting data on a preterm infant, the nurse finds that the infant has early onset jaundice. What advice should the nurse give to the infant's mother?

"Breast feed the infant frequently."

While caring for a newborn, the nurse finds that the child regurgitates after feeding. What does the nurse conclude from this finding?

The newborn has an immature cardiac sphincter.

While collecting data on a newborn, the nurse finds that the newborn has swelling of the soft tissues of the scalp. What does the nurse infer from this finding?

The newborn has caput succedaneum.

The computed tomography scan report of the newborn shows that the anterior fontanel measures 3.6 cm. It also shows that the fontanel appears flat with the contour of the skull. What does the nurse interpret from these findings?

The newborn is normal.

The nurse is teaching the parents of a preterm baby about proper skin care. Which action of the parents indicates the need for additional teaching?

The parents clean the baby with an alkaline soap.

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?

The passage of bloody mucous stool

The nurse is collecting data on a male neonate immediately after birth. The nurse finds that the neonate has hypospadias. Which findings enabled the nurse to reach this conclusion?

The presence of the urethral opening on the underside of the penis

After collecting data on a newborn, the nurse instructs the newborn's parent to hold the newborn in an upright position on the shoulder and rock the infant in a vertical fashion. What is the reason for this advice?

To keep the newborn alert

The nurse is caring for a posterm infant. Which physical characteristics would the nurse observe in the infant? Select all that apply.

Dry skin with cracks Long nails stained with meconium Body covered with a lesser amount of lanugo

Which technique promotes body flexion in the preterm infant?

Infant nesting

The nurse is caring for a newborn who has been placed under a phototherapy lamp. What will the nurse say to the newborn's parents to reduce panic?

"Your child will pass greenish stool."

Which are inborn metabolic genetic disorders? Select all that apply.

Cystic fibrosis Phenylketonuria

What are the physical characteristics seen in preterm infants?

Protruding abdomen Abundant vernix caseosa Presence of superficial veins

The nurse is caring for a preterm infant with respiratory distress syndrome. The infant is on oxygen therapy and has edema and atelactasis. The primary health care provider instructs the nurse to prolong the supplemental oxygen therapy. Which complication does the nurse expect to find in the preterm infant in the future?

The infant may have bronchopulmonary dysplasia.

The nurse, while collecting data, finds that the long nails of an infant are meconium-stained. What does the nurse interpret from this finding?

The infant was born after 42nd week of gestation.

The ultrasound scan of a patient, who has multigestational pregnancy, shows the presence of malformed placenta. What outcome would the nurse anticipate from this finding?

The infants may be discordant twins.

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse instructs the infant's parent to place the infant on the right side after feeding. What is the rationale behind this instruction?

To prevent regurgitation

The nurse is caring for a pregnant patient who has reduced amounts of surfactant in the amniotic fluid. The primary health care provider instructs the nurse to administer betamethasone (Celestone) to the patient 24 hours before the delivery. What could be the reason for this intervention?

To prevent respiratory distress syndrome in the fetus

A preterm newborn with respiratory distress is placed in the prone position during care. After a few days of treatment, the primary health care provider observes that the newborn is stable and instructs the nurse to gradually change the newborn's sleeping position from prone to supine. What is the rationale behind this instruction?

To prevent sudden infant death syndrome

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, the nurse might suspect that the newborn has which condition?

Tracheoesophageal fistula

What parameter can be determined by using the Maximo-Pronto-7 pulse oximeter?

Transcutaneous hemoglobin level

The infant is at risk for developing hypocalcemia.

infant is fed cow's milk. The laboratory report of the neonate indicates increased serum phosphate levels. What does the nurse infer from this finding?

The nurse is caring for an infant born at 43 weeks of gestation. The nurse finds that the infant has polycythemia. What other complication does the nurse expect to find in the infant?

Hyperbilirubinemia

While caring for a neonate, the nurse finds that the neonate's body has little downy hair. The neonate's skin is dry, pale, and covered with very little vernix caseosa. Which complications would the nurse anticipate in the neonate?

Hypoxia Polycythemia Hypoglycemia

A child with hydrocephalus has increased blood pressure, decreased pulse rate, and decreased respirations. What does the nurse suspect these symptoms indicate?

Increased intracranial pressure

Which nursing diagnosis would be the priority in newborns?

Ineffective thermoregulation

While collecting data on a 2-day-old infant, the nurse finds that the infant has anemia. After 2 days, the nurse observes that the infant is having seizures. What other complication does the nurse expect to find in the infant? Select all that apply.

Kernicterus Hyperbilirubinemia

Which foods should be removed from the diet of an infant with spina bifida? Select all that apply.

Kiwi Bananas Avocados

The nurse is collecting data on a 2-year -old child. The nurse finds that the child has a red-purple lesion on the face and neck. The parents report that the mark on the face and neck has been growing darker since the child was born. What treatment strategy does the nurse expect to be beneficial for the child?

Laser surgery

What terminology will the nurse use when considering how well developed an infant is at birth and the ability of the organs to function outside the uterus?

Level of maturation

A newborn is diagnosed with clubfoot that responds positively to simple exercise. What type of intervention does this type of clubfoot require?

Manipulative exercises

The parent of an infant with increased serum potassium levels adds calcium lactate powder to the formula as prescribed by the primary health care provider. During the follow-up visit, the primary health care provider advises the parent to discontinue adding calcium lactate to the formula. What is the priority nursing intervention in this situation?

Monitor the infant for signs of neonatal tetany.

Which are causes of preterm birth?

Multiple gestations Alcohol consumption High maternal blood pressure

The nurse is caring for a preterm infant who is on hypertonic gavage feeding. Which complication would the nurse expect to find in the infant?

Necrotizing enterocolitis

The nurse is caring for a postpartum patient. On reviewing the patient's medical history, the nurse finds that the patient was on amphetamine drug therapy during pregnancy. Which complication does the nurse expect to find in the patient's newborn?

Neonatal abstinence syndrome

A child with impaired bladder sphincter functioning has tufts of hair, lipoma, and discoloration at the lumbosacral region. What do these findings indicate?

The infant has spina bifida occulta.

While collecting data on a term infant, the nurse finds that the infant is at risk of developing hypocalcemia. Which findings enabled the nurse to reach this conclusion?

The infant is fed preterm formula.

While collecting data on an infant, the nurse finds that the infant has eczema, seizures, and decreased skin elasticity. The nurse also observes that the infant has signs of mental retardation. Which laboratory test does the nurse expect to be prescribed for the infant?

Guthrie Blood test

The nurse is collecting data on a neonate using New Ballard Score. After performing maturational assessment of the neonate, the nurse documents the total neuromuscular maturity score as 20 and the total physical maturity score as 25. What is the gestational age of the neonate?

42 The gestational age of a neonate can be identified by using the New Ballard Score. In this system, the nurse checks neuromuscular development and physical maturity in the newborn and gives a score for each. By adding these two scores, the nurse can find the total maturity score and the gestational age of the newborn. If the neuromuscular maturity score is 20 and the total physical maturity score is 25, then the total maturity rating would be 45. According to the New Ballard score, total maturity score of 45 indicates that the gestational age of the neonate is 42 weeks.

A preterm infant in the NICU is receiving calcium gluconate for hypoglycemia. What assessment would the nurse prioritize?

Heart rate

What diagnostic assessment is used to diagnose phenylketonuria?

A Guthrie blood test

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

A normal finding

What is the best phase to initiate bonding between the parent and the infant?

First reactive phase

A preterm infant has a distended abdomen, immature respiratory center, and a weak gag reflex. Which treatment strategy would be beneficial for the infant?

Administering warm, humidified oxygen via nasal catheter

A newborn has undergone circumcision and has edema and yellow crust on the penis. The nurse finds that the newborn is bleeding at the site of circumcision. What is the priority nursing intervention in this situation?

Apply gentle pressure to the site with a sterile gauze pad.

The nurse is caring for a 1-month-old infant with asymmetric skin folds in the upper thighs and the head of the femur is partially displaced. The primary health care provider has prescribed a spica cast for the infant. Which interventions help to provide effective care for the infant? Select all that apply.

Applying a Bradford frame to the infant Changing the infant's position frequently Placing a pillow beneath the curvature of the cast

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action would be the best?

Document the findings.

What are the factors that interfere with ventilation during neonatal oxygenation?

Edema Atelectasis Thickened lung membranes

The nurse is collecting data on an infant who underwent circumcision. To identify the severity of pain, the nurse observes the infant's facial expressions, cry, movement of the arms and the legs, consolability, and oxygen saturation to give a score using a 10-point scale. Which pain assessment tool is the nurse using to record the severity of pain?

CRIES scale

The nurse is caring for a preterm infant who has weak sucking and swallowing reflexes. The primary health care provider instructs the nurse to prepare the infant for the insertion of a feeding tube. What should the nurse do before feeding the infant?

Check for the passage of meconium.

The nurse is collecting data on an infant and finds that the infant has chest retractions and noisy respirations. The infant's pulse rate is 120 beats/min, the blood pressure is 80/46 mm Hg, and the respiratory rate is 40 breaths/min. Which findings will lead the nurse to immediately notify the primary health care provider? Select all that apply.

Chest retractions in the infant Noisy respiration in the infant

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?

Covering the bladder with a sterile, nonadhering moist dressing

The nurse is caring for an infant who has transient tachypnea (TTN). Which interventions does the nurse expect to be beneficial for the infant? Select all that apply.

Covering the infant with a warm blanket Keeping the infant calm by swaddling Administering oxygen supplement to the infant

What are the symptoms of respiratory distress in the newborn? Select all that apply.

Grunting Flaring of nares Cyanosis

Which diagnosis does a positive Barlow's test confirm?

Developmental hip dysplasia

The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be appropriate?

Document the findings.

Which disorder is associated with the accumulation of cerebrospinal fluid in the ventricles of the newborn's brain?

Hydrocephalus

While collecting data on a 2-day-old newborn, the nurse finds that the infant's respiratory rate is 80 breaths/min, pulse rate is 180 beats/min, and body temperature is 39.7°C. What will be the first intervention followed by the nurse in this situation?

Notifying the primary health care provider

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are in which location?

Outside of the abdominal cavity but covered with a translucent sac

The nurse is caring for an infant who has ABO-Rh incompatibility. Which complication would the nurse expect in the infant?

Pathological jaundice

The nurse is caring for a 4-month-old infant with developmental hip dysplasia. Which treatment strategy does the nurse expect to be most beneficial for the infant?

Pavlik harness

What physical characteristic most likely indicates postmaturity?

Peeling skin

While collecting the data on an infant, the nurse finds that the infant has hypotonia, convulsions, and irregular respirations. The nurse also observes that the infant has poor feeding. Which intervention does the nurse expect to be suitable for diagnosing the infant's illness?

Performing a blood test "Maple syrup dx"

The nurse is caring for an infant with impaired Moro reflex. The nurse finds that the infant's urine, sweat, and earwax have a sweet odor. Which treatment strategy does the nurse expect to be beneficial for the infant?

Performing peritoneal dialysis "Maple Syrup"

The nurse is caring for a preterm infant who has intracranial hemorrhage. The nurse observes that the infant has convulsions and twitching. Which medication does the nurse expect to be beneficial for the infant to alleviate the symptoms of intracranial hemorrhage?

Phenobarbital (Luminal)

The nurse is caring for a preterm infant placed in an incubator. What nursing intervention promotes circadian rhythms in the infant?

Placing the blanket on the top of the incubator

The nurse is caring for an infant who has undergone surgery for hydrocephalus. The nurse finds that the infant has increased intracranial pressure and bulged fontanelles. Which interventions will be beneficial to the infant? Select all that apply.

Placing the infant in the semi-fowler's position Placing an internal flushing device in the shunt

A preterm infant with hypoglycemia is lethargic and found to have bradycardia. What is the priority nursing intervention in this situation?

Placing the infant under a radiant warmer

Identify the physical characteristics that would be present in an infant with respiratory distress syndrome.

Respiratory rate above 60 breaths/min Grunting and retractions Edema

What is usually included in parent teaching for newborn care before discharge? Select all that apply.

Return appointments for well-baby care Proper use of car safety seats Basic infant care

What are the symptoms of kernicterus? Select all that apply.

Seizures Lethargy Opisthotonus position (arched back)

What will the nurse check to determine the hydration status of the newborn? Select all that apply.

Stool consistency Tissue turgor Appearance of sunken fontanelles

While caring for a preterm newborn, the nurse finds that the newborn has breathing difficulty and a heart rate of 90 beats/minute. The nurse starts rubbing the newborn's feet, ankles, and back gently, but finds this intervention to be ineffective. Which interventions would be beneficial to alleviate the newborn's symptoms?

Suctioning the newborn's nose and mouth Raising the newborn's head to the semi-Fowler position Connecting an ambu bag to the newborn's mask

Which chemical is necessary for the absorption of oxygen by the lungs?

Surfactant

While caring for a preterm infant, the nurse notices that the parents are scared to take care of the baby. Which nursing intervention will help the parents provide effective care to the infant? Select all that apply.

Teach the parents to feed and bathe the infant. Encourage the parents to look at and touch the infant. Assist the parents in providing kangaroo-care for the infant.

The nurse is collecting data on an infant who has a flat nose, round face, upward-slanting eyes, and protruding tongue. On reviewing the prenatal test reports, the nurse finds that the infant's mother tests positive for the pregnancy-associated plasma protein A (PAPP-A) test and quad test. What does the nurse infer from these findings?

The infant has Down syndrome.

The nurse is caring for a 3-day-old infant. The nurse finds a lump on one side of the infant's head. On reviewing the neural exam report of the infant, the nurse finds that the parietal bones in the infant's head have overridden each other. What does the nurse interpret from these findings? Select all that apply.

The infant has cephalohematoma. The infant's head has undergone molding during labor.

The nurse is caring for an infant with jaundice who has been prescribed phototherapy. On reviewing the medical history of the infant, the nurse finds that phototherapy is contraindicated in the infant. Which findings support the nurse's conclusion?

The infant has congenital porphyria.

The nurse is caring for an infant who is thin and has an enlarged head. The nurse finds that the infant has a shrill cry, poor muscle tone, vomiting, and anorexia. What does the nurse infer from these findings?

The infant has hydrocephalus.

While collecting data on a newborn, the nurse finds that the newborn's skin has a yellowish tinge. On reviewing the laboratory report, the nurse finds that the plasma bilirubin levels are 5mg/dL. What does the nurse infer from these findings?

The infant has icterus neonatorum.

While caring for a preterm infant, the nurse finds that the infant has cold stress. Which findings in the infant enabled the nurse to reach this conclusion?

The infant has lethargy. The infant has mottling of the skin. The infant has periods of apnea.

The nurse is caring for a newborn infant who weighs 5 kg. The nurse finds that the infant has a round and puffy face. The nurse also finds that the infant's mother had gestational diabetes. What does the nurse infer from these findings?

The infant has macrosomia.

While collecting data on an infant, the nurse finds that the infant has white pinpoint "pimples" on the nose and chin. What does the nurse infer from this finding?

The infant has milia.

the infant has white pinpoint "pimples" on the nose and chin. What does the nurse infer from this finding?

The infant has milia.

The infant is at risk for developing hypocalcemia.

infant is fed cow's milk. increased serum phosphate levels. What does the nurse infer from this finding?

What is the most common type of birth injury?

intracranial hemorrhage