Neonatal and High-Risk Neonatal Management
A breastfeeding mother is being discharged with her 2-day-old, full-term newborn. The nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement? 1. "He should have at least three wet diapers tomorrow." 2. "He should have one stool per day during the next week." 3. "At his 1-week checkup, he should weigh an additional 8 ounces." 4. "He should nurse for 5 minutes on each breast to get enough milk."
1. "He should have at least three wet diapers tomorrow." This statement indicates the mother's understanding. A 3-day-old infant should produce at least 3 week diapers. After 5 days of age, the newborn should produce 6 well-saturated diapers per day
A healthy postpartum mother who is breastfeeding her term infant states, "My roommate is feeding her newborn iron-enriched formula. Should I be giving my baby iron?" Which response by the nurse is correct? 1. "Your breast milk provides all the iron your baby needs." 2. "You, not your baby, will need an iron supplement daily." 3. "Your pediatrician will prescribe iron drops for your baby." 4. "You should feed your baby iron-fortified formula once daily."
1. "Your breast milk provides all the iron your baby needs." It is unnecessary to provide iron supplementation to a breastfeeding infant. Although iron content in breast milk is much lower than an iron-fortified formulas, the iron in breast milk is much more completely absorbed
The nurse is discharging the 3-day-old term newborn with a right-sided cephalohematoma. The nurse should instruct the parents to observe their infant closely over the next week for the development of which problem associated with cephalohematoma? 1. Jaundice 2. Difficulty feeding 3. Pale extremities 4. Bulging on the right side of the head with crying
1. Jaundice A cephalohematoma is the collection of blood between a skull bone and its periosteum. As the hematoma resolves, hemolysis of RBCs occurs, and jaundice may result. A cephalohematoma will resolve without treatment by 3 to 6 weeks
The postpartum client (G2P2) asks the nurse for suggestions to help facilitate her 3-year-old's attachment and acceptance of their newborn. Which action should the nurse suggest? 1. Provide a doll for the 3-year-old to care for and nurture 2. Avoid bringing the 3-year-old to the "scary" hospital 3. Plan that dad cares for the 3-year-old and mom cares for the baby 4. Encourage the child to be "grown up" and accept the newborn
1. Provide a doll for the 3-year-old to care for and nurture Providing care to a doll encourages the 3-year-old to identify with the parents, which helps to decrease anger and regression to get attention
The nurse evaluates that the newborn's Moro reflex is WNL. Which response by the newborn prompted the nurse's conclusion? 1. Straightens extremities and then flexes them in response to a loud noise 2. Right-side extremity extension when the head is quickly turned right 3. Turns the head toward the right side when the right cheek is touched 4. Attempts to walk when the stole of the foot touches a hard surface
1. Straightens extremities and then flexes them in response to a loud noise An intact Moro reflex is demonstrated when the newborn straightens the extremities and then flexes them in response to a loud noise
The nurse completed discharge education to the Native American parents of a 48-hour-old, full-term infant. The nurse concludes that the mother needs additional teaching about jaundice when she makes which statement? 1. "I know keeping my baby warm will help decrease jaundice." 2. "I know that jaundice should start to decrease after about 3 days." 3. "The bilirubin causing the jaundice is eliminated in my baby's stools." 4. "Feeding my baby frequently will help to decrease the jaundice."
2. "I know that jaundice should start to decrease after about 3 days." Peak bilirubin levels are reached at 3 to 5 days of age for Caucasian infants. However, Native American babies have higher bilirubin levels than Caucasian babies, and the jaundice persists for longer periods with no apparent ill effects
The agitated father of the 12-hour-old newborn reports that his baby's hands and feet are blue. After confirming the presence of acrocyanosis, what should the nurse do next? 1. Immediately stimulate the infant to cry 2. Explain that this is normal in a newborn 3. Assess the newborn's temperature 4. Assess the newborn's cardiac status
2. Explain that this is normal in a newborn Acrocyanosis, which is blueness of hands and feet, is a normal newborn phenomenon in the first 24 to 48 hours after birth. The nurse should explain this to the father to relieve his anxiety
The nurse meets the frantic father at an ED door. He says he just delivered his wife's full-term newborn in the car when the temperature outside is only 10F (-12.2C). In response to the cold environment, the nurse knows that the infant's body will immediately begin to produce heat by which mechanism? 1. Shivering 2. Metabolizing body fat 3. Dilating surface blood vessels 4. Decreasing flexion of the extremities
2. Metabolizing body fat When skin receptors of full-term newborns perceive a drop in environmental temperature, the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat, thus producing heat that is transferred to the peripheral circulation
The client with oligohydramnios and possible intrauterine growth restriction gives birth. The newborn's 1-minute Apgar score was 6, and the 5-minute Apgar score is 7. Which conclusion should the nurse make from this information? 1. A low Apgar score at 1 minute correlates with infant mortality 2. The 5-minute Apgar score of 7 is within normal parameters 3. Neurological problems are unlikely with a 5-minute score of 7 4. Oligohydramnios would not have affected the Apgar score
2. The 5-minute Apgar score of 7 is within normal parameters A 5-minute Apgar score at or above 7 is considered normal
The nurse is caring for the client who has just given birth. The mother is O negative. The nurse should assess for ABO incompatibility and hyperbilirubinemia if the infant's blood type is which type? 1. O positive 2. O negative 3. A negative 4. Any type
3. A negative The nurse should assess for ABO incompatibility when the infant's blood type is A negative. The mother's type O blood has no antigens on the RBCs, whereas the infant has A antigens
The nurse is caring for a 30-year-old, single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client's lifestyle? 1. Observe how the client interacts with her hospital visitors 2. Review the prenatal record for clues about the client's lifestyle 3. Ask the client what plans she has made for newborn care at home 4. Observe the relationship between the client and her newborn's father
3. Ask the client what plans she has made for newborn care at home Open-ended questions will encourage sharing of feelings and examination of available lifestyle options. A lower income and lack of a reliable backup person are common problems for single parent
While supervising the LPN, the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse's conclusion? 1. Assessed the newborn's HR apically 2. Covered the newborn's head with a stocking cap 3. Checked the newborn's temperature rectally 4. Positioned the newborn supine while sleeping
3. Checked the newborn's temperature rectally The LPN needs additional instruction when observed monitoring the newborn's temperature rectally. Taking the temperature rectally may cause rectal mucosal irritation and increase the chances of rectal perforation
The mother of a healthy 15-hour-old term newborn states, "We are going home. Should the PKU blood test be completed on my baby before we leave?" Which statement should be the basis for the nurse's response? 1. The PKU test must be completed when the infant is at least 1 month of age 2. The parents must skin a consent form if the PKU test is completed before 24 hours of age 3. The PKU test is best if completed after the infant is 24 hours old but before 7 days of age 4. The PKU test is not needed if the infant is tolerating feedings without diarrhea or vomiting
3. The PKU test is best if completed after the infant is 24 hours old but before 7 days of age The PKU test should be performed after 24 hours of life and before the infant is 7 days old. This allows for sufficient intake of protein for accurate results
The nurse assesses that the full-term newborn's head has molding. Considering this finding, which information should the nurse expect to see on the mother's labor and delivery documentation? 1. Vaginal breech birth 2. Planned cesarean birth, no labor 3. Was in labor for 16 hours 4. Precipitous delivery after a 30-minute labor
3. Was in labor for 16 hours A 16-hour labor will cause molding. Molding is a change in the shape of the fetal skull from the force of uterine contractions during labor pressing the vertex of the head against the cervix. The degree of molding varies with the amount and length of pressure exerted on the head. Thus a longer labor will increase molding
The home-care nurse is educating the parents of a 1-week-old newborn. Which instruction should the nurse include about the care of the newborn's umbilical cord? 1. "Begin applying rubbing alcohol to the base of the cord stump three times a day." 2. "Attempt to gently dislodge the cord if it has not fallen off in the next week." 3. "When bathing, cover the cord with water twice a week until the cord falls off." 4. "Continue to place the diaper below the cord when diapering the infant."
4. "Continue to place the diaper below the cord when diapering the infant." Folding the diaper below the cord avoids cord contact with urine and stool. A wet, soiled environment slows drying and increases the risk of infection
The nurse finds documentation in the 4-hour-old newborn's medical records that states, "Clamping of the umbilical cord was delayed until cord pulsations ceased." When assessing and collecting additional information about the newborn, what effect should the nurse find as a result of the delayed cord clamping? 1. More rapid expulsion of meconium by the newborn 2. Increased level of newborn alertness after birth 3. An increase in the newborn's initial temperature 4. An increase in the newborn's hemoglobin and hematocrit
4. An increase in the newborn's hemoglobin and hematocrit Newborn Hgb and Hct values will be higher when placental transfusion, accomplished through delayed cord clamping, occurs at birth. Blood volume increases by up to 50% with delayed cord clamping
The nurse is about to perform a heel stick on a 32-weeks' gestation infant to obtain blood for a prescribed test. Which intervention should the nurse utilize to minimize the neonate's pain? 1. Apply an ice pack 2. Apply a heel warmer 3. Give morphine sulfate 4. Give sucrose or Sweet-Ease
4. Give sucrose or Sweet-Ease Sucrose activates the endogenous opioid system through taste. It is given 2 minutes prior to a painful procedure and has an analgesic effect lasting about 3 to 5 minutes
The nurse is admitting a neonate after delivery who is diagnosed with a myelomeningocele. Which intervention should the nurse implement immediately? 1. Positions the infant prone and covers the sac with sterile gauze 2. Notifies the surgeon on call that the infant is ready for surgery 3. Applies a pressure dressing to the sac and starts an intravenous access 4. Positions the infant prone, hips slightly flexed, and legs abducted
4. Positions the infant prone, hips slightly flexed, and legs abducted Positioning the infant prone with hips slightly flexed and legs abducted helps to minimize tension and potential for rupture of the sac
The nurse is assessing the infant who may have FAS. Which findings, if observed, should the nurse associate with FAS? (Select all that apply) 1. Broad nasal bridge and flat midface 2. Growth deficit in weight and length 3. Excessive irritability and hypotonia 4. Poor feeding and persistent vomiting 5. Large jaw and overdeveloped maxilla
1, 2, 3, 4 1. Broad nasal bridge and flat midface 2. Growth deficit in weight and length 3. Excessive irritability and hypotonia 4. Poor feeding and persistent vomiting Classic dysmorphic facial features such as a broad nasal bridge and flat midface are associated with FAS due to the effects of alcohol on the developing fetus Growth deficiency is associated with FAS due to the deprivation of nutrients needed for growth Various nervous system abnormalities including irritability and hypotonia are associated with FAS due to the effects of alcohol on the developing fetus Poor feeding and persistent vomiting are associated with FAS due to facial abnormalities and problems with digestion
The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn's axillary body temperature between 97.7F (36.5C) and 98.9F (37.2C)? (Select all that apply) 1. Carefully dry the infant immediately after birth 2. Place the infant skin-to-skin with the mother 3. Apply leggings to both of the newborn's legs 4. Cover the infant's head with a stocking cap 5. Place the infant in a bassinette close to the wall
1, 2, 4 1. Carefully dry the infant immediately after birth 2. Place the infant skin-to-skin with the mother 4. Cover the infant's head with a stocking cap Drying the newborn immediately after birth prevents heat loss through evaporation Skin-to-skin contact between mother and baby at birth assists to maintain newborn body temperature The newborn's head is dried first after birth, and a stocking cap is placed on the head to conserve heat
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn's circumcision? (Select all that apply). 1. Monitor the newborn's penis hourly for 4 to 6 hours 2. Observe for and document the first voiding after circumcision 3. Use prepackaged commercial diaper wipes for perineal cleansing 4. Apply petroleum ointment around the penis after each diaper change 5. Apply a size-smaller diaper tightly to provide hemostasis
1, 2, 4 1. Monitor the newborn's penis hourly for 4 to 6 hours 2. Observe for and document the first voiding after circumcision 4. Apply petroleum ointment around the penis after each diaper change After circumcision, the newborn's penis should be closely monitored, especially for swelling and bleeding To evaluate for urinary obstruction, the infant should be monitored frequently for the first urination postcircumcision, and this finding should be documented Petroleum and gauze should be applied to the circumcision site with each diaper change to prevent bleeding and to protect healing tissue
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter, which actions should be planned by the nurse? (Select all that apply) 1. Check the position marking on the catheter every shift 2. Position the tubing close to the infant's lower limbs 3. Check for erythema or discoloration of the abdominal wall 4. Palpate for femoral, pedal, and tibial pulses every 2 to 4 hours 5. Reposition the catheter tubing every hour 6. Monitor blood glucose levels
1, 3, 4, 6 1. Check the position marking on the catheter every shift 3. Check for erythema or discoloration of the abdominal wall 4. Palpate for femoral, pedal, and tibial pulses every 2 to 4 hours 6. Monitor blood glucose levels
Calculating from the date of the mother's last menstrual period, the nurse determines that her newborn's gestational age is 40 weeks. Which normal findings should the nurse expect when assessing this newborn at birth? (Select all that apply) 1. Hypertonic flexion of all extremities 2. Sole creases on the anterior two-thirds of the sole 3. Well-defined incurving of the entire ear pinna 4. Presence of a prominent clitoris 5. Infant is able to support the head momentarily when pulled to a sitting position
1, 3, 5 1. Hypertonic flexion of all extremities 3. Well-defined incurving of the entire ear pinna 5. Infant is able to support the head momentarily when pulled to a sitting position As the fetal muscular tone matures, the posture becomes more flexed; thus the full-term newborn exhibits hypertonic flexion of all extremities Cartilage gives the ear its shape. At full term, the newborn ear has enough cartilage to produce a well-defined incurving of the entire pinna The full-term infant has the muscle strength to momentarily support his or her head when pulled to a sitting position
The nurse is preparing the parents of a full-term, 24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? (Select all that apply). 1. Infant vital signs have been normal for the last 12 hours 2. The infant has passed at least three meconium stools 3. The infant has gained weight at the minimum 100 grams 4. The circumcision has had no bleeding for the last 2 hours 5. The infant has had six diaper changes in the last 24 hours 6. The infant has completed two successful consecutive feedings
1, 4, 6 1. Infant vital signs have been normal for the last 12 hours 4. The circumcision has had no bleeding for the last 2 hours 6. The infant has completed two successful consecutive feedings The American Academy of Pediatrics has determined that newborn discharge criteria include stable VS for 12 hours No bleeding from a circumcision for 2 hours is an expected discharge criterion Completing two successful consecutive feedings in included in the discharge criteria. Successful feedings include verification that the infant is able to coordinate sucking, swallowing, and breathing while feeding
The nurse is measuring both the chest and head circumference during the full-term newborn's initial assessment. The newborn's father observes this and asks the nurse why both measurements are necessary. Which explanation is most accurate? 1. "Comparing the measurements helps determine if there are head or chest size abnormalities." 2. "Measuring the head circumference provides information about future intellectual ability." 3. "Measuring the newborn's chest provides needed information when assessing cardiac health." 4. "Comparing the head and chest measurements helps to determine future adult body size."
1. "Comparing the measurements helps determine if there are head or chest size abnormalities." The circumference of the normal newborn's head is approximately 2 centimeters greater than the circumference of the newborn's chest at birth. Any extreme difference in head size may indicate microcephalus, hydrocephalus, or increased ICP
While caring for the small-for-gestational-age newborn (SGA), the nurse notes slight tremors of the extremities, a high-pitched cry, and an exaggerated Moro reflex. In response to these assessment findings, what should be the nurse's first action? 1. Assess the infant's blood sugar level 2. Document the findings in the infant's medical record 3. Immediately inform the pediatrician of the symptoms 4. Assess the infant's axillary temperature
1. Assess the infant's blood sugar level The nurse should first check the infant's blood sugar level. SGA infants are at risk for hypoglycemia because they have poor hepatic glycogen stores and inadequate supplies of enzymes to activate gluconeogenesis
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment? 1. Bulging anterior fontanel 2. Head and chest circumference equal 3. A narrowed posterior fontanel 4. Low-set ears
1. Bulging anterior fontanel A bulging anterior fontanel is an initial sign of congenital hydrocephalus
As the nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis in the full-term newborn, the newborn's father asks if it is really necessary to put something into his baby's eyes. Which statement should be the basis for the nurse's response? 1. It is the law in the U.S. that newborns receive this prophylactic treatment 2. This treatment is recommended but may be omitted at the parent's verbal request 3. The antibiotic used for the treatment can be given orally at the parent's request 4. The eye prophylaxis can be given any time up until the infant is 1 year old
1. It is the law in the U.S. that newborns receive this prophylactic treatment Currently every U.S. state requires that newborns receive prophylactic eye treatment against gonorrheal conjunctivitis
When assessing the infant undergoing phototherapy for hyperbilirubinemia, the nurse notes a maculopapular rash over the infant's buttock and back. What action should the nurse take next? 1. Document the results in the newborn's record 2. Call the HCP immediately to report this finding 3. Discontinue the phototherapy immediately 4. Assess the infant's axillary temperature
1. Document the results in the newborn's record As a side effect of phototherapy, some newborns develop a transient maculopapular rash that does not require treatment. The only action required is to document the findings
The labor history of a postpartum mother states, "Mother positive for group B streptococcal (GBS) infection at 37 weeks' gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks' gestation. Precipitous labor, no antibiotic given." Considering this information, the nurse should observe the 15-hour-old newborn closely for which finding? 1. Temperature instability 2. Pink stains in the diaper 3. Meconium stools 4. Presence of erythema toxicum
1. Temperature instability The infant can be infected with GBS from the mother and may start to exhibit symptoms within the first 12 to 24 hours after birth. Temperature instability is one of the most common early symptoms
The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? (Select all that apply) 1. Have the mother nap before interacting with her newborn 2. Dim the lights in the birthing room 3. Place the newly delivered infant on the mother's abdomen 4. Delay instilling the ophthalmic antibiotic for an hour 5. Play loud music to keep the infant stimulated 6. Ask the parents to delay phone calls for an hour after birth
2, 3, 4, 6 2. Dim the lights in the birthing room 3. Place the newly delivered infant on the mother's abdomen 4. Delay instilling the ophthalmic antibiotic for an hour 6. Ask the parents to delay phone calls for an hour after birth Dimming the lights in the birthing room encourages the newborn to open his or her eyes. This in turn encourages eye contact between the parent and the newborn Skin-to-skin contact between mother and baby at birth improves mother-baby interaction Instillation of ophthalmic antibiotic ointment should be delayed for an hour because instilling it now may cause temporary blurred vision in the newborn. The temporary blurred vision can decrease the infant's ability to engage in eye-to-eye contact with the parents, thus affecting parent-infant attachment The newborn is alert for up to 1 hour after birth. Parents should be encouraged to use this time for attachment and to delay phone calls
The nurse completes teaching in preparation to discharge a mother and her 48-hour-old, full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn's father is overhead making which statement? 1. "We need to face the infant car seat toward the back of the car." 2. "I disarmed one front seat air bag so we can put the car seat in the front seat." 3. "Let's check the car seat to make sure it will position the baby at a 45-degree angle." 4. "I know the baby will need to be in the infant car seat until he is over 20 pounds."
2. "I disarmed one front seat air bag so we can put the car seat in the front seat." The parents should be advised not to disarm air bags and that the rear vehicle seat is the safest place for children of any age to ride
The nurse has provided the mother with information about her newborn's milia. The nurse evaluates that the mother understands information when the mother makes which statement? 1. "I will put lotion on my infant's nose in the morning and at night." 2. "I understand there raised white spots will clear up without treatment." 3. "I realize the baby will need surgery to remove these skin lesions." 4. "I will apply alcohol twice a day to the lesions until they disappear."
2. "I understand there raised white spots will clear up without treatment." This statement indicates the mother understands information about milia. No treatment is necessary because it will clear spontaneously within the first month
After assisting in the delivery of a full-term infant with anencephaly, the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse's response? 1. Immediate surgery is necessary to repair the congenital defect 2. Anencephaly is incompatible with life; only palliative care should be provided 3. A shunting procedure will be necessary initially to relieve intracranial pressure 4. Antibiotics are needed initially before any treatment is started
2. Anencephaly is incompatible with life; only palliative care should be provided Anencephaly is the absence of both cerebral hemispheres and of the overlying skull. It is a condition that is incompatible with life
The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice? 1. Remove the infant's diaper and look at the color of the genitalia 2. Apply pressure on the forehead for 3 seconds, release, and evaluate the skin color 3. Assess the color of the palms and compare that skin color to the color of the soles 4. Open the infant's mouth to assess the color of the infant's tongue and palate
2. Apply pressure on the forehead for 3 seconds, release, and evaluate the skin color To differentiate cutaneous jaundice from normal skin color, the nurse should apply pressure with a finger over a bony area such as the forehead. If jaundice is present, the blanched area will look yellow before the capillaries refill
The client, who is a primiparous lesbian, delivered a term newborn. The client is in a monogamous relationship with a female partner and achieved her pregnancy via articical insemination. Which intervention should the nurse add to the newborn's care plan? 1. Avoid acknowledging the client's lesbian relationship 2. Encourage the client's partner to participate in newborn cares 3. Ask the partner to leave the room when the newborn is present 4. Avoid telling the newborn's caregivers about the client's situation
2. Encourage the client's partner to participate in newborn cares The nurse should involve the partner in the newborn's care. This shows the partner the same respect, caring, and attention shown to the partners of heterosexual mothers
During an assessment of the full-term, 1-hour-old newborn, the nurse obtains an apical HR of 120 bpm and auscultates a soft murmur at the left sternal border, third intercostal space. In response to these assessment findings, which action should be taken by the nurse? 1. Immediately report the findings to the HCP 2. Document the HR and murmur 3. Recheck the murmur to the left side-lying position 4. Stimulate crying and then reassess the cardiac status
2. Document the HR and murmur Documentation of the findings is all that is required. Both the HR and murmur are expected findings. The apical HR of the term newborn is normally between 100 and 160 bpm. A murmur heard at the sternal border, third intercostal space, is most likely caused by delayed closure of the foramen ovale, which functionally closes within 1 to 2 hours after birth. Permanent closure of the foramen ovale occurs within 6 months to 1 year after birth
The nurse assesses that the 8-hour-old infant's axillary temperature is 97F (36.1C). Which intervention should the nurse implement first? 1. Document the findings as normal 2. Place the infant under a radiant warmer 3. Feed the infant formula that is warmed 4. Call the HCP to report the temperature
2. Place the infant under a radiant warmer This infant's axillary temperature of 97F (36.1C) is below the normal range of 97.7F (36.5C) to 98.9F (37.2C). The infant should be gradually rewarmed under a temperature-controlled radiant warmer
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help this baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect? 1. Increase Paco2 levels in the bloodstream 2. Prevent collapse of the alveoli 3. Decrease Pao2 levels in the bloodstream 4. Prevent pleural effusion
2. Prevent collapse of the alveoli Surfactant replacement therapy decreases alveolar collapse that occurs with RDS and thus decreases the severity of RDS
While performing an initial assessment on the full-term infant whose parents are Asian, the nurse notes the skin discoloration illustrated. What should be the nurse's interpretation of this finding? 1. The infant was bruised during or after the delivery 2. This is a normally occurring skin variation in newborns 3. Hurriedly placing the infant supine can cause this bruising 4. Seepage of blood from the intestine occurred during the birth process
2. This is a normally occurring skin variation in newborns The image is illustrating Mongolian spots, a normal newborn skin variation
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse, "Something black is coming out of my baby." After determining that the newborn has passed stool, which statement by the nurse is most appropriate? 1. "Black stools could be from bleeding. I will notify your provider now." 2. "Breastfeeding will cause all the baby's stools to be this dark in color." 3. "Babies normally pass this type of stool initially; it is called meconium." 4. "I'll check the baby's temperature; this occurs when babies need warming."
3. "Babies normally pass this type of stool initially; it is called meconium." The majority of full-term infants will normally pass the first meconium stool within 24 hours after birth. It is formed during fetal life from amniotic fluid and intestinal secretions and cells. It is greenish-black in color and normally contains occult blood
While preparing parents of a 2-day-old, bottle-feeding newborn for discharge, the nurse recognizes the parents' need for additional teaching about formula feeding. Which statement prompted the nurse's conclusion? 1. "We plan to clean our baby's bottles in the dishwasher." 2. "Placing the formula in a bowl of warm water will warm it." 3. "We will put the bottle of unfinished formula in the refrigerator." 4. "Using our city tap water to mix the powdered formula is safe."
3. "We will put the bottle of unfinished formula in the refrigerator." The formula remaining in the bottle after feeding has mixed with the infant's saliva and should be discarded, not refrigerated; formula is a good medium for bacterial growth
The nurse admits the term newborn, who is at risk to develop neonatal abstinence syndrome (NAS), to the newborn nursery. The nurse correctly places this infant in which location? 1. The general nursery with 15 other infants 2. A small, well-lit nursery with two other newborns 3. Alone in a small, darkened nursery room 4. Right next to the charge nurse's desk
3. Alone in a small, darkened nursery room The newborn with NAS will exhibit withdrawal behaviors due to exposure to chemical substances in utero. The nurse should place the newborn alone in a small, darkened nursery room to reduce environmental stimuli
The nurse evaluates a preterm infant after a gavage feeding. The nurse determines that feeding intolerance has developed when which finding is noted during assessment? 1. The infant immediately falls asleep after feeding 2. The gastric residual is zero prior to the next feeding 3. The infant's abdominal girth has increased in size 4. The infant is having soft, loose stools
3. The infant's abdominal girth has increased in size Signs of feeding intolerance in preterm infants include increasing abdominal girth and abdominal distention. Feeding intolerance may indicate paralytic ileus or NEC
When the nurse is preparing the 48-hour-old, full-term infant for discharge, the nurse learns that the couple has not named their infant. Which action should the nurse take in response to this information? 1. Ask the parents to choose a name before discharge 2. Encourage other appropriate attachment behaviors 3. Document the discharge and that the baby is unnamed 4. Delay discharge until parental attaching is addressed
3. Document the discharge and that the baby is unnamed In some cultures, the naming of a child is an important event, and the day is marked by a celebration. The naming of the child may not occur until the third day or later after birth. Thus the only response is to document this information
The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: "40 weeks' gestation, large for gestational (LGA) age." In response to this information, it is most important for the nurse to plan to assess the infant carefully for which condition? 1. Acrocyanosis 2. Undescended testicles 3. Intact clavicles 4. Hypothermia
3. Intact clavicles A major complication for LGA infants is birth trauma, such as a fractured clavicle, due to cephalopelvic disproportion from macrosomia
A new mother of a full-term, 7-lb newborn asks the nurse how to ensure that her baby is taking the correct amount of formula at each feeding. The nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. How many ounces of formula should her infant be eating every 4 hours? _______ ounces (Record your answer to the nearest tenth)
3.5 Multiplying 3 ox by 7 (the weight of the baby) equals 21 oz needed per day. Dividing 21 oz by 6 (the number of feedings in 24 hours if the baby is fed every 4 hours) equals 3.5 oz per feeding
The nurse is preparing a bolus gavage feeding for the preterm infant who has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant's stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps to complete this feeding. 1. Separate the barrel of the syringe from the plunger and connect the syringe barrel to the feeding tube 2. Remove the syringe and clear the tubing with 2 to 3 mL of air 3. Elevate the syringe 6 to 8 inches over the infant's head 4. Position the infant on the right side 5. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate 6. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel 7. Cap the lavage feeding tube
4, 1, 6, 3, 5, 2, 7 4. Position the infant on the right side 1. Separate the barrel of the syringe from the plunger and connect the syringe barrel to the feeding tube 6. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel 3. Elevate the syringe 6 to 8 inches over the infant's head 5. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate 2. Remove the syringe and clear the tubing with 2 to 3 mL of air 7. Cap the lavage feeding tube
The nurse is caring for a preterm infant with respiratory distress syndrome (RDS). Which intervention should the nurse implement to maximize the infant's respiratory status? 1. Check blood glucose levels every 4 hours 2. Cool and humidify all inspired gases 3. Weigh the infant every other day 4. Place the infant in a prone position
4. Place the infant in a prone position The prone position allows for better oxygenation of collapsed alveoli. Because the prone position is associated with sudden infant death, infants placed in this position should have continuous cardiorespiratory monitoring
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn's HR is 80 bpm. Which intervention should the nurse implement next? 1. Assign a 2 for the Apgar score that pertains to the HR 2. Suction the excess secretions from the newborn's oral cavity 3. Wrap in warm blankets and place on the mother's abdomen 4. Begin immediate positive pressure ventilation on the newborn
4. Begin immediate positive pressure ventilation on the newborn A newborn HR of less than 100 bpm scores a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff ventilation
The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which action should be taken by the nurse? 1. Have the mother breastfeed her newborn now 2. Immediately feed the infant water with 10% dextrose 3. Report the results immediately to the HCP 4. Document the information in the newborn's medical record
4. Document the information in the newborn's medical record Normal blood sugar values for a full-term newborn are 45 to 65 mg/dL. Therefore, the only action required is to document the findings
The full-term newborn is placed under phototherapy lights to treat hyperbilirubinemia. The nurse should assess the newborn for dehydration due to which effect of phototherapy? 1. Decreased sodium absorption 2. Increases absorption of bilirubin 3. Decreased urinary output 4. Increases insensible water loss
4. Increases insensible water loss Insensible water loss (IWL) are significantly increased in infants who are treated with phototherapy. Additional water losses may occur with increased stooling associated with either the elimination of bilirubin or a temporary lactose intolerance resulting from exposure to phototherapy
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn's anterior fontanel by which method? 1. Lay the infant on his or her back 2. Stimulate the infant to cry strongly 3. Feel near the parietal and occipital bones 4. Place the infant in a sitting position
4. Place the infant in a sitting position To assess the anterior fontanel, the nurse should place the infant in a sitting position (45 to 90 degrees) so its location, size, and any abnormalities can be identified. If indented-appearing, it could indicate dehydration; if bulging, it could indicate increased ICP
The nurse and student nurse are caring for the postpartum client who delivered a term newborn 24 hours previously. The nurse recognizes that the student needs more information on newborn nutrition when making which statement? 1. About half of the baby's calories needs are met by the fat in breast milk or formula 2. Lactose is the primary source of carbohydrates in breast milk and formula 3. Calcium supplements are not needed for the newborn regardless of the feeding method 4. Supplemental water should be given to all infants daily, regardless of feeding method
4. Supplemental water should be given to all infants daily, regardless of feeding method Breast milk and formula contain almost 90% water, which meets the infant's water needs. Feeding supplemental water can cause hyponatremia and may result in seizures if water consumption is excessive
Before beginning a newborn's physical assessment, the nurse reviews the newborn's medical record and sees this notation: "31 weeks' gestation." Considering this information, the nurse determines that a physical assessment of the infant should reveal which finding? 1. Flexion of all four extremities 2. The ability to suck 3. The absence of lanugo 4. Vernix covering the infant
4. Vernix covering the infant The preterm infant, 24 to 36 weeks' gestation, typically is covered with vernix caseosa - a waxy, white substance secreted by the fetus's sebaceous glands in utero
An infant had four wet diapers during the 8-hour shift. The weight of a dry diaper is 15 g. The four wet diapers weighed 30 g, 24 g, 21, g, and 25 g. What amount in milliliters should the nurse record for the total 8-hour urine? _________ mL (Record your answer as a whole number)
40 If a dry diaper weighs 15 g, subtract that weight from the weight of each of the infant's diapers: 30 g - 15 g = 15 g, 24 g - 15 g = 9 g, 21 g - 15 g = 6 g, 25 g - 15 g = 10 g. Then add all of the totals: 15 g + 9 g + 6 g + 10 g = 40 g of fluid loss, which equals 40 mL of urine output
