Maternity CH. 18 PrepU

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? When the infant is 48 hours old 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents Just before discharge home

24 hours after the newborn's first protein feeding Explanation: The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Lower rate of urinary tract infections Reduced risk of penile cancer Fewer complications than if done later in life Anesthetic may not be effective during the procedure

Anesthetic may not be effective during the procedure Explanation: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? Temperature of 97.8°F Heart rate 158 Respiratory rate 42 Blood sugar 42 mg/dL

Blood sugar 42 mg/dL Explanation: Any blood sugar lower than 50 mg/dL is considered hypoglycemic and should be further assessed. In the scenario described, the infant's temperature, heart rate, and respiratory rate are all considered within normal limits.

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? Mongolian spot cavernous hemangioma infantile (strawberry) hemangioma nevus flammeus

Mongolian spot

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply. Jitteriness Diaphoresis Low body temperature Increased appetite Irritability

Jitteriness Low body temperature Irritability Explanation: A newborn who is experiencing hypoglycemia will exhibit several signs that need to be recognized. They include jitteriness, irritability, listlessness, low body temperature and poor feeding. The newborn will not be diaphoretic.

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? "The baby may have a problem; let's schedule an appointment." "This can be related to cleaning her perineal area; be more careful." "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." "If this continues, call us back; for now, just watch her."

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." Explanation: The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia? Bradycardia Hyperglycemia Metabolic alkalosis Shivering

Bradycardia

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Rocking and talking to the infant Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back

Feeding the infant more formula whenever she begins to fuss Explanation: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? respiratory rate of 50 breaths/minute acrocyanosis asymmetrical chest movement short periods of apnea (less than 15 seconds)

asymmetrical chest movement Explanation: Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? Apgar score blood sugar heart rate temperature

blood sugar Explanation: Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Wipe the tongue off vigorously to remove the white patches. Rinse the tongue off with sterile water and a cotton swab. Since it looks like a milk curd, no action is needed. Report the finding to the pediatrician.

Report the finding to the pediatrician. Explanation: Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "We should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "It is best practice to change the diaper every 2 to 4 hours, even during the night."

"We will fold down the front of her diaper under the umbilical cord until it falls off." Explanation: In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? Alert the primary care provider stat, and turn the newborn to her right side. Administer oxygen via facial mask by positive pressure. Lower the newborn's head to stimulate crying. Aspirate the oral and nasal pharynx with a bulb syringe.

Aspirate the oral and nasal pharynx with a bulb syringe. Explanation: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation

Convection Explanation: There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? Use of pass codes onto the unit Use of monitor attached to babies Use of cameras at all doors Cooperation by the parents with the hospital policies

Cooperation by the parents with the hospital policies Explanation: The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Recheck blood pressure in 15 minutes. Put warming blanket over infant. Document normal findings.

Document normal findings. Explanation: These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6&%176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

Why are newborns born to diabetic mothers prone to hypoglycemia? Excess subcutaneous fat reduces blood flow to the tissues. Metabolic stress is increased due to the stress on the mother's body. Elevated insulin production metabolized glucose faster. The liver is immature and cannot convert glycogen to glucose.

Elevated insulin production metabolized glucose faster. Explanation: When the mother is diabetic, she has levels of insulin and blood sugars different from a pregnant woman without diabetes. Therefore the infant/fetus develops elevated levels of insulin to combat the elevated sugars. The infant is then at risk of low blood sugar once he or she is born. Infants born to diabetic mothers do not have excess subcutaneous fat that reduces blood flow to the tissues; they do not have increased metabolic stress because of stress on the mother's body; and their immature liver is not the reason the newborn is prone to hypoglycemia.

The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. Excessive fluid in its lungs, making respiratory adaptation more challenging. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. Much of the fetal lung fluid is squeezed out in cesarean delivery.

Excessive fluid in its lungs, making respiratory adaptation more challenging. Explanation: During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean delivery without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths.

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply. Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Place the newborn in isolation precaution. Bathe the newborn thoroughly.

Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly. Explanation: When a mother has a positive test for hepatitis B surface antigen (HBsAg), the newborn is given the hepatitis B vaccine and hepatitis B immune globulin. Consent must be obtained before administering vaccinations. The newborn should be bathed to remove traces of blood and attempt to limit transmission. Standard precaution should be followed.

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress? The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. It takes energy to keep warm, so the neonate has to remain in an extended position. If the neonate becomes cold stressed, it will eventually develop respiratory distress.

If the neonate becomes cold stressed, it will eventually develop respiratory distress. Explanation: If cold stressed, the infant eventually will develop respiratory distress- O2 requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. Bundling and using a hat will help prevent heat loss by evaporation which can lead to cold stress. It is better if the neonate remains in a flexed position as it will assist with keeping warm. The neonate should stabilize its temperature by 8 hours as long as proper measures are followed.

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? Assess the newborn's gestational age. Rewarm the newborn gradually. Observe the newborn every hour. Notify the primary care provider if the temperature goes lower.

Rewarm the newborn gradually. Explanation: A newborn's temperature is typically maintained at 97.7° F to 99.7° F (36.5° C to 37.5° C). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the primary care provider of the newborn's current temperature since it is outside normal parameters.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? The cardiac murmur heard at birth disappears by 48 hours of age. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Heart rate remains elevated after the first few moments of birth. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Explanation: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement? Drowsy Quiet alert Active alert Active attentive

Quiet alert Explanation: A newborn that has its eyes open but is quiet and observing people and things around him is in the quiet alert state. The active alert state is characterized by the newborn having the eyes open but is moving about. The drowsy state shows the newborn whose eyes are open and closing with heavy eyelids and is intermittently fussy. There is no "active attentive" state according the Neonatal Behavioral Assessment Scale.

The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first? Seizure Respiratory distress Cardiovascular distress Hypoglycemia

Respiratory distress Explanation: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.

Which action will the nurse avoid when performing basic care for a newborn male? Inspecting the genital area for irritated skin Palpating if testes are descended into the scrotal sac Determining the location of the urethral opening Retracting the foreskin over the glans to assess for secretions

Retracting the foreskin over the glans to assess for secretions Explanation: The foreskin in male newborns does not normally retract and should not be forced. The nurse will inspect the genital area for irritated skin to prevent and/or treat possible skin irritations. The nurse will palpate the testes to determine if the newborn has cryptorchidism. It is important to verify that the urethral opening is at the tip of the glans and not on the dorsal or ventral sides as these would need intervention. This can be accomplished without overmanipulating the foreskin.

A nurse is doing an admission assessment on a female infant born to a primipara. Which findings would warrant notification of the physician? Select all that apply. Heart rate of 150 Scaphoid abdomen Episodic breathing Head circumference of 38 cm Overlapping cranial sutures

Scaphoid abdomen Head circumference of 38 cm Explanation: A heart rate from 100 to 160 is considered a normal range for a newborn. The newborn will also exhibit an episodic breathing pattern, where the respirations are irregular with small pauses interspersed with rapid respirations. Overlapping cranial sutures are also normal, especially as this is the mother's first baby. The two abnormal findings are the scaphoid abdomen, which should be rounded or protuberant, and the head circumference (HC) of 38 cm. A normal HC is 33 to 35.5 cm.

Which statement is false regarding bathing the newborn? To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing should not be done until the newborn is thermally stable. While bathing the newborn, the nurse should wear gloves. Mild soap should be used on the body and hair but not on the face.

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Explanation: Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? blood pressure pulse temperature respirations pain

blood pressure Explanation: Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: molding. microcephaly. caput succedaneum. cephalohematoma.

caput succedaneum. Explanation: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalohematoma is a localized effusion of blood beneath the periosteum of the skull.

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? respiratory rate 45 breaths/minute, irregular costal breathing pattern nasal flaring, rate 65 breaths/minute crackles on auscultation

respiratory rate 45 breaths/minute, irregular Explanation: Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.