Newborn Assessment Elsevier Q'tions
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? A.) In utero through the placenta B.) In the postpartum period through breast milk C.) During birth through contact with the maternal vagina D.) After the birth through a blood transfusion given to the mother
A --Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.
During the physical assessment of a recently born neonate, the nurse palpates the infant's femoral pulses. For which cardiac defect is the nurse looking? A.) Atrial septal defect B.) Coarctation of the aorta C.) Patent ductus arteriosus D.)Ventricular septal defect
B --Coarctation of the aorta results in diminished or absent femoral pulses. An atrial septal defect has no effect on the volume of peripheral circulation. (Minimal shunting occurs in the newborn period.) A patent ductus arteriosus has minimal effect on the volume of peripheral circulation (left-to-right shunt). A ventricular septal defect has minimal effect on the volume of peripheral circulation (left-to-right shunt)
client and her 2-week-old newborn are scheduled to be seen by the visiting nurse at home. When the nurse arrives, the client appears exhausted and the infant is crying. After comforting the client, what is the nurse's most appropriate comment? A.) "Are you feeling all right?" B.) "Tell me about your daily routine." C.) "You must be having a terrible day." D.) "When was the baby's last feeding?"
B ---Learning about the client's routine permits collection of more data. Asking whether the client is feeling all right implies that the client is not well enough to care for her baby. A negative comment closes communication. Asking about the last feeding may make the mother feel guilty about not meeting her baby's needs.
A nurse assesses a newborn 1 minute after birth. The body is pink with blue extremities; the heart rate is 122 beats/min; the legs are withdrawn when the soles are flicked, respiration is easy, with no evidence of distress; and the arms and legs are flexed and moving vigorously. What Apgar score should the nurse document in the newborn's medical record? A.) 7 B.) 8 C.) 9 D.) 10
C --One point was removed from the Apgar score because the extremities are blue. Scores of 7 and 8 are too low and do not reflect the status of the newborn. A score of 10 is too high and does not reflect the status of the newborn.
A nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? A.) Limiting caloric intake to decrease metabolic rate B.) Maintaining the prone position to prevent aspiration C.) Limiting oxygen concentration to prevent eye damage D.) Maintaining a high-humidity environment to promote gas exchange
D -- The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible. Caloric intake is increased; the amount, number, and type of feedings are related to the metabolic rate. Infants should be placed in a side-lying rather than a prone position; the prone position is associated with apnea and sudden infant death syndrome. Limiting oxygen concentration to prevent eye damage is not a routine action; the concentration of oxygen depends on the oxygen concentration of the neonate's blood gases.
A preterm infant, born at 30 weeks' gestation, is receiving an intravenous electrolyte solution at a rate of 20 mL/hr by way of an umbilical arterial line. At the hourly intake measurement, the nurse observes that 40 mL has infused in the past hour. What is the nurse's first intervention? A.) Taking the vital signs B.) Comparing the intake with the ouput C.) Checking the practitioner's prescriptions D.) Slowing the infusion rate to half of the prescribed rate
A ---The priority is assessing the infant for circulatory overload; changes in the vital signs may indicate a problem that must be addressed quickly. Comparing the intake and output record wastes valuable time that should be spent assessing the infant's response. Checking the practitioner's prescription wastes valuable time that should be spent assessing the infant's response. After the infant's response is assessed, an adjustment of the IV rate may be prescribed.
The nurse is assessing a 12-hour-old newborn. What clinical finding should be reported to the health care provider? A.) Jaundice B.)Cephalhematoma C.) Erythema toxicum D.) edematous genitalia.
A --Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.
A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are absent from the ready-to-use formulas. The nurse responds that the supplement that is not in ready-to-use formulas is: A.) Iron B.) Fluoride C.) Vitamin K D.) Vitamin B12
B --The use of fluoride supplements has become a controversial issue. The Centers for Disease Control and Prevention still recommends it. The recommended amount is 0.25 mg daily if fluoridated water is not available. Commercial formulas are fortified with iron. The supply of vitamin K is adequate after the first week of life. Vitamin B12 supplementation is unnecessary; the formula contains vitamin B12
A nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? A.) Persistent diarrhea B.) Decreased abdominal circumference C.) Small amount of vomitus after each gastric feeding D.) Increased amount of residual gastric volume from earlier feedings
D ---An increasing residual volume without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate because the cardiac (lower esophageal) sphincter of the stomach is weak.
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect? A.) Tetany B.) Spina bifida C.) Hyperkalemia D.) Intercranial hemmorrhage
D --Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement. Tetany is caused by hypocalcemia; it is manifested by exaggerated muscle twitching. Spina bifida is a defect of the spinal column that is observed at birth. An increased potassium level causes cardiac irregularities, not the irritable behavior observable with central nervous system involvement.
A male born at 28 weeks' gestation weighs 2 lb 12 oz. What does the nurse expect to note when performing an assessment? a.) Staring eyes B.) Absence of lanugo C.) Descended testicles D.) Transparent red skin
D --Transparent red skin is expected because of the absence of subcutaneous fat tissue. Preterm infants born nearer to term have open, staring eyes. Preterm infants generally are born with large amounts of lanugo, which begins to thin just before term and by 40 weeks is found only on the shoulders, back, and upper arms. The preterm infant's scrotum is small and the testicles usually are high in the inguinal canal
A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent: A.) Failure to thrive B.) Cognitive impairment C.) Growth restriction D.) Specific food allergies
B ---Screening for PKU facilitates early diagnosis and treatment, which can prevent mental retardation. Although children with untreated PKU do have problems with physical growth and may exhibit failure to thrive, the major purpose of the test is to prevent the development of cognitive impairment. Telling the parent that this test is performed to prevent specific food allergies is not accurate because this is not a test for food allergies; it tests for an inborn error of metabolism, PKU.
A nurse is assessing a newborn. Which sign should the nurse report? A.) Temperature of 97.7° F (36.5° C) B.) Pale-pink to rust-colored stain in the diaper C.) Heart rate that decreases to 115 beats/min D.) Breathing pattern with recurrent sternal retractions
D --This infant's breathing pattern is indicative of respiratory distress; the expected pattern is abdominal with synchronous chest movement. A temperature of 97.7° F (36.5° C) is within the expected range of 97.6° F (36.4° C) to 99° F (37.2° C) for a newborn. Pale-pink to rust-colored staining in the diaper is caused by uric acid crystals from the immature kidneys; it is a common occurrence. A decrease in heart rate to 115 beats/min is within the expected range of 110 to 160 beats/min for a newborn.
A client is rooming in with her newborn. The nurse sees the infant lying quietly in the bassinet with the eyes open wide. What action should the nurse take in response to the infant's behavior? A.) Brightening the lights in the room B.) Encouraging the mother to talk to her baby C.) Wrapping and then turning the infant to the side D.) Beginning physical and behavioral assessments
B --A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother-infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed.
A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first? A.) The term infant with a heart rate of 158 beats/min 1 hour after birth B.) The mother who has saturated one peripad over the 4 hours since delivery C.)The mother with a white blood cell count of 12,500/mm3 24 hours after delivery D.) The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth
D ---The appearance of jaundice during the first 24 hours of life or persistence beyond the ages delineated usually indicates a potential pathologic process that requires further investigation. The white blood cell count increase is normal after birth, possibly a result of to stress and tissue trauma during the birthing process. The acceptable range for the newborn heart rate is 110 to 160 beats/min. Saturating more than one pad per hour with lochia rubra is a matter of concern because it is less than the acceptable limit.