newborn fall 2020

A nurse is caring for a newborn who is approximately 13 hours old. On assessment, the nurse notes a yellow tint to the newborn's skin and sclera. What laboratory tests should the nurse anticipate? Select all that apply.

a direct Coombs test a total bilirubin test a hemoglobin test Explanation: A newborn with signs of jaundice who is less than 24 hours old often has Rh or ABO incompatibility. A test called a direct Coombs is ordered to see if maternal antibodies are circulating in the newborn's blood. A total bilirubin test helps determine the total amount of bilirubin in the blood to assess the risk of increased jaundice. A hemoglobin test will show if there is a decrease in red blood cells. A serum glucose test would be used in hypoglycemia of a newborn, and a blood culture would be used to detect sepsis of a newborn.

The nurse is providing bag and mask ventilation during newborn resuscitation. What assessment data will the nurse collect to evaluate the effectiveness of this action? Select all that apply.

adequate pulse oximetry readings presence of bilateral breath sounds heart rate greater than 100 bpm Explanation: During effective bag and mask resuscitation there will be adequate oxygen saturation, bilateral breath sounds, and heart rate greater than 100 beats per minute. Distal extremities may exhibit acrocyanosis, and BP is not a direct measure of effectiveness of bag and mask resuscitation.

A nurse is assessing a preterm newborn for possible sepsis. The nurse suspects an early onset infection based on which risk factors? Select all that apply.

preterm labor prolonged rupture of membranes maternal fever Explanation: Risk factors for early onset neonatal infection include preterm labor, prolonged rupture of membranes, and maternal fever. An immature immune system and decreased gastric acid are risk factors for intrauterine infection.

A newborn is being admitted to the intensive care unit with the diagnosis of postterm infant. Which nursing actions would be the priority? Select all that apply.

Monitor for hematocrit levels. Assess for jaundice. Initiate blood glucose monitoring. Explanation: Postterm infants will need to be monitored closely for alterations in blood glucose levels. The nurse should also closely assess the postterm infant for polycythemia, which contributes to hyperbilirubinemia, so jaundice would be an indicator. Hct levels will be monitored for the risk of polycythemia. RH factor is not a priority. Temperature monitoring is a standard for all newborn care.

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.

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.

During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. What findings would correlate with this suspicion? Select all that apply.

The newborn has green staining of the fingernails. The newborn has labored abdominal respirations. The newborn makes bearing down movements. Green amniotic fluid is present at birth. Explanation: Meconium aspiration is evidenced by the presence of green amniotic fluid with rupture of membranes during labor. There is green staining of the umbilical cord or fingernails. The newborn struggles with breathing by making respiratory efforts and bearing down with abdominal muscles to expel meconium. Fontanel assessment does not apply at this time. Bright red staining on the umbilical cord at birth is normal.

A nurse is assessing a newly admitted newborn who is 2 hours old. Which assessment findings would concern the nurse? Select all that apply.

The newborn has visible bilateral nasal flaring. The newborn has visible chest retractions. Explanation: The signs and symptoms of respiratory distress include tachypnea, periodic breathing, apnea, retractions, nasal flaring, grunting, pallor, and cyanosis. These findings require interventions. The blue hands and feet, apical pulse rate, and minimal response to voices are all appropriate for a newborn who is two hours old.

A nurse is teaching a new mother about how newborns regulate their temperature. As part of the teaching, the nurse explains brown fat. Which information would the nurse include? Select all that apply.

Brown fat is brown and rich in blood vessels and nerve endings. The newborn keeps itself warm by oxidizing brown fat in response to exposure to the cold. Only mature newborns have brown fat. The most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals. Explanation: Brown fat, a special tissue found in mature newborns, helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. The greatest amounts of brown fat are found in the intrascapular region, the thorax, and behind the kidneys and makes up 2% to 6% of a term newborn's body weight. It is brown in color and rich in blood vessels and nerve endings. The newborn will oxidize the brown fat in response to exposure to the cold and help warm up their body.

The nurse is bathing a newborn for the first time. Place in order how the nurse would perform these tasks during the bathing procedure. Use all options.

Fill a tub with warm water and add a mild soap. Using a soft washcloth, wash the newborn all over. Comb the hair to remove any dried blood. Take the newborn's axillary temperature. Cover the head with a cap, apply a diaper and dress the newborn. Swaddle in a warm blanket and place in an open crib. Explanation: Thermoregulation is the most important part of bathing a newborn. The nurse will take the newborn's temperature and, once it is stable, the newborn is bathed. Warm water with a mild soap is used, and the entire body is bathed. Any dried blood in the hair or on the head is removed gently with a comb. After the bath is complete, the newborn's axillary temperature is taken and, if it's above 97.7°F (36.5°C), the newborn is dressed, swaddled in a warm blanket and placed in an open crib.

A nurse is teaching a new mother about her neonate and the changes that are occurring as the neonate adapts to life outside the client's uterus. The nurse would incorporate understanding of which change when describing the neonate's current status? Select all that apply.

Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes. Explanation: With the neonate, the lungs are now responsible for gas exchange, and the respiratory system is an air-filled, low-pressure system. Hepatic portal circulation begins with closure of the ductus venosus. The neonate's body temperature is maintained through a flexed posture and brown fat.

The nurse collects a history on a newly pregnant woman. Which data does the nurse identify in the health history that places this client at risk for having an infant with a chromosomal anomaly? Select all that apply.

Maternal age 37 years Sister with Down syndrome Explanation: Risk factors for having an infant with a chromosomal anomaly include advanced maternal age (older than 35 years) and family history (sister with Down syndrome). Number of previous pregnancies, obstetric complications such as gestational diabetes, or previous preterm birth are not risk factors for chromosomal problems in future pregnancies.

Which nursing interventions are essential when caring for a newborn with macrosomia born to a mother with diabetes? Select all that apply.

Obtain blood glucose reading. Obtain IV glucose for potential infusion. Assess for respiratory distress. Anticipate supplemental oxygen. Explanation: Newborns of mothers with diabetes require careful observation. Frequent blood glucose checks begin after birth. Administering feeding early maintains the blood glucose level. If the newborn cannot tolerate feedings, obtain IV glucose for infusion. Monitor for respiratory distress and anticipate supplemental oxygen therapy and surfactant therapy.

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply.

Place an identification band on both the mother and the newborn immediately after birth, before separating them. Explanation: When a newborn is born, three to four identical bracelets are prepared and placed on both the mother and the infant with pertinent data such as mother's name, hospital number, date of birth, time of birth, the newborn's gender along with the health care provider for the mother. Thumbprints are not a reliable way to identify a newborn and mother. Nurses compare information on the bands, not in the chart. The nurse would never ask the parents to identify their newborn by appearance since newborns look a lot alike. Lastly, it may be hard to keep the newborn with the parents all the time due to health care provider visits and procedures such as circumcisions.

A nurse is caring for a newborn with meconium aspiration syndrome. Which interventions should the nurse perform when caring for this newborn? Select all that apply.

Place the newborn under a radiant warmer or in a warmed isolette. Administer oxygen therapy. Administer broad-spectrum antibiotics. Explanation: When caring for a newborn with meconium aspiration syndrome, the nurse should place the newborn under a radiant warmer or in a warmed isolette, administer oxygen therapy as ordered via a nasal cannula or with positive pressure ventilation, and administer broad-spectrum antibiotics to treat bacterial pneumonia. Repeated suctioning and stimulation should be limited to prevent overstimulation and further depression in the newborn. The nurse should also ensure minimal handling to reduce energy expenditure and oxygen consumption that could lead to further hypoxemia and acidosis. Handling and rubbing the newborn with a dry towel is needed to stimulate the onset of breathing in a newborn with asphyxia.

Which result of a biophysical profile would indicate to the nurse that the fetus might tolerate labor poorly? Select all that apply.

a nonreactive nonstress test (NST) low amniotic fluid volume placental grade III Explanation: A nonreactive NST, low amniotic fluid volume, and placental grade III are indicators of minimal reserves and that the fetus may not be able to tolerate the stress of labor. A positive stress test and poor fundal growth are also signs that the fetus is at risk, but they are not components of the biophysical profile.

What are the causes of retinopathy of the preterm newborn? Select all that apply.

assistive ventilation with high oxygen content fragility of blood vessels in the eyes in response to changes on oxygenation. shock Explanation: Retinopathy of the preterm newborn typically develops in both the eyes secondary to an injury such as hyperoxemia resulting from prolonged assistive ventilation and high oxygen exposure, fragility of retinal blood vessels in response to changes in oxygenation, and shock. Alkalosis does not contribute to this problem; acidosis does.

A nurse is assessing a term neonate and notes transient tachypnea. When reviewing the mother's history, which conditions would the nurse most likely find as contributing to this finding? Select all that apply.

cesarean birth use of heavy sedation during labor Explanation: If fluid is removed too slowly or incompletely (e.g., with decreased thoracic squeezing during birth or diminished respiratory effort), transient tachypnea (respiratory rate above 60 bpm) of the newborn occurs. Examples of situations involving decreased thoracic compression and diminished respiratory effort include cesarean birth and sedation in newborns. Research findings support the need for thoracic compression because the absence of the neonate's exposure to labor contractions, which may occur with cesarean births or heavy sedation during the labor process or general anesthesia administered during the surgical birth, is associated with an increased risk of transient tachypnea at term.

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency Explanation: Fetal growth restriction can result from aneuploidy, congenital malformations, infections, or uteroplacental insufficiency. Their size falls below the 10th percentile on growth charts. It is the pathological counterpart to a SGA. They are at risk for increased morbidity and mortality. The fetus is thought to have growth potential under normal circumstances. It is analogous to the failure to thrive in the infant. Newborns that experience nutritional deficiencies in utero and born with FGR are at risk of lifelong developmental deficits.

A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply.

"Try swaddling her nice and snuggly." "Try shushing her loudly." "Encourage her to suck." Explanation: Recent research outlines five things (the five "S") that parents can do to calm a fussy infant: swaddling tightly; using the side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; and sucking (Karp, 2014).

A neonatal nurse admits a preterm infant with the diagnosis of respiratory distress syndrome and reviews the maternal labor and birth record. Which factors in the record would the nurse correlate with this diagnosis? Select all that apply.

32 weeks' gestation cesarean birth male gender newborn asphyxia maternal diabetes Explanation: The most common risk factor for the development of RDS is premature birth. Additional risk factors include cesarean birth, male gender, perinatal asphyxia, and maternal diabetes. Age of the mother and hypertension are not factors in the development of RDS.

The charge nurse hears the call, "Shoulder dystocia in room 4." What resources will the charge nurse dispatch to room 4 to assist with this situation? Select all that apply.

Anesthesia Surgeon Pediatrician Explanation: The resources the charge nurse will call include anesthesia, pediatrician, and surgeon. A social worker may be needed later, but is not needed during the delivery process. The rapid response team is not specific to the needs of this client's situation.

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply.

Assess the newborn's skin. Increase fluid intake. Maintain protective cover around infant. Remove the infant to feed and change. Explanation: Nursing interventions are different when utilizing phototherapy lights and a fiberoptic blanket. The main difference is that the fiberoptic blanket does not require the newborn to maintain eye shields. All the other options are correct.

A hepatitis B positive mother delivers a newborn. What precautions would the nurse take in caring for this infant? Select all that apply.

Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth. Explanation: Mothers who are hepatitis B positive run a high risk of transmitting the disease to their newborns if the infant is not treated immediately and precautions taken. Bathing immediately after birth is one precaution. Additionally, the newborn receives the HBV vaccination along with a one-time dose of hepatitis B immunoglobulin.

A nurse is conducting an in-service education program for a group of nurses working in the newborn nursery. The nurse has explained the events that occur as fetal circulation transitions to newborn circulation. The nurse determines the session is successful after the participants put the chain of events in which order? All options must be used.

Birth occurs. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes. Explanation: Immediately after birth, pulmonary vascular resistance decreases, and pulmonary blood flow increases. This happens secondary to an increase in PO2 as a result of the first breath and umbilical cord clamping. An increase in left atrial pressure causes the foramen ovale to close. This leads to a continued increase in systemic blood pressure with continued increase of blood flow to the lungs. The ductus arteriosus closes a few hours after birth.

The administration of caffeine has become common in NICU infants with apnea of prematurity. The NICU nurse explains the advantages of this medication to the parents and knows the parents understood when they make which statements? Select all that apply.

Caffeine stimulates the breathing center of the preterm infant's brain. Caffeine has a superior safety profile with fewer side effects than theophylline. Caffeine improves the rate of recovery when used in conjunction with CPAP therapy. The neonate can be discharged home while taking caffeine, as it can be given orally. Explanation: Caffeine citrate has a superior safety profile with fewer side effects than theophylline, and it improves the rate of recovery when used in conjunction with CPAP therapy. Because it is available in an oral preparation, the parents can administer this at home after discharge. Caffeine sodium benzoate is contraindicated in neonatal treatment of apnea.

The nurse is reviewing the laboratory test results of a newborn. Which results would the nurse identify as normal? Select all that apply.

hemoglobin 17 g/dL platelets 200,000 u/L red blood cells 5.3 (1,000,000/uL) Explanation: Normal newborn lab values are as follows: hemoglobin 16 to 18 g/dL; hematocrit 46% to 68%; platelets 150,000 to 350,000 u/L; red blood cells 4.5 to 7.0 (1,000,000/uL); and white blood cells 10 to 30,000/mm3. In this situation, the newborn's hemoglobin, red blood cells, and platelets cells are normal.

In the hour immediately following the birth of an infant with a physical challenge, what is a nursing care priority? Select all that apply.

determining the infant's immediate physiologic needs promoting bonding between parents and the newborn Explanation: Nursing priorities include determining physiologic needs and promoting bonding. Outlining long-term implications, referring to genetics, and exploring behaviors that may have contributed to the condition can all be delayed until a later time.

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns. Explanation: To prevent injury from hypoglycemia, prevention of hypoglycemia is critical. Breastfeeding mothers are encouraged to begin feedings early and continue on a frequent basis. Bottle-fed newborns require early feedings as well. Thermoregulation can also help maintain a newborn's blood glucose. Doing a heel stick blood glucose is a good idea for a lethargic newborn but will not prevent hypoglycemia from occurring. Glucose water feedings are no longer recommended.

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.

Lanugo on the back Milia Acrocyanosis Explanation: A full-term newborn may have thin patches of lanugo over his back, shoulders or arms. He may also have milia, which appear as white papules on the face. Acrocyanosis at 3 hours of age is also a normal finding. However, this should resolve by 24 to 48 hours of age. A newborn at 3 hours of age should never have jaundice. Vernix on the abdomen and lower extremities is seen in preterm infants, not full-term ones.

When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used.

Pink coloration is lost. Respiratory effort decreases. Muscle tone decreases. Reflex irritability is noted. Heart rate decreases. Explanation: The Apgar score is a method of evaluating a newborn's physical condition at 1 and 5 minutes after birth. Assessment is an indication of the newborn's overall central nervous system status. When the newborn experiences physiologic depression, the characteristics disappear in a predictable manner: first the pink coloration is lost, next the respiratory effort, then the tone, followed by reflex irritability, and finally the heart rate.

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply.

Place the infant on his or her back. Do not allow anyone to smoke around the infant. Explanation: Although the specific cause of SIDS cannot be explained, these interventions have been shown to decrease the incidence of the syndrome: place infant on the back to sleep; use a firm sleep surface; breastfeeding; room sharing without bed sharing; routine immunizations; consideration of using a pacifier; avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs.

A newborn with newly diagnosed hemolytic jaundice is being treated with phototherapy. Which actions should the nurse take? Select all that apply.

Shield the newborn's genitals and eyes during phototherapy sessions. Encourage the mother to breastfeed (8 to 12 feedings per day). Supplement breast milk with formula. Expose as much of the newborn's skin as possible. Explanation: For the newborn receiving phototherapy, place the newborn under the lights or on the fiber-optic blanket, exposing as much skin as possible. Cover the newborn's genitals and shield the eyes to protect these areas from becoming irritated or burned when using direct lights. Assess the intensity of the light source to prevent burns and excoriation. Turn the newborn every 2 hours to maximize the area of exposure, removing the newborn from the lights only for feedings. Maintain a neutral thermal environment to decrease energy expenditure, and assess the newborn's neurologic status frequently. Research is finding that intermittent versus continuous phototherapy is as efficacious to lower bilirubin levels. Assess the newborn's temperature every 3 to 4 hours as indicated. Monitor fluid intake and output closely.

The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would the nurse expect to communicate about this newborn? Select all that apply.

Sunken abdomen Poor muscle tone over buttocks Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used.

Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate. Explanation: Commonly the first step in a nursing intervention cascade is assessment. However, the nurse already has assessed that the newborn is term, is not crying, and has decreased tone that would require intervention. The first step is to warm the newborn and then to decrease any further loss of heat through evaporation by drying the newborn. The airway should be cleared before the newborn is stimulated to avoid aspiration. The nurse would then check the heart rate to see if further resuscitation efforts are necessary.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation. Explanation: Following circumcision, the nurse will monitor the newborn for bleeding, voiding and pain. A spot larger than the size of a quarter, not a dime, is reported to the physician. The penis is washed in warm water with no soap with each void. Diapers are left loose so as to not press on the newly circumcised penis. Talc powder is never used when changing diapers. The newborn is given 12 hours to void before the nurse becomes concerned.

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness Explanation: The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low-pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia.

At birth, an infant is below average in weight, length, and head circumference and has a high hematocrit level. Which problem would the nurse assess for in this infant? Select all that apply.

low glucose level high bilirubin level prolonged acrocyanosis cold stress Explanation: This infant is exhibiting signs of intrauterine growth retardation. Infants who are small for gestational age have problems with thermoregulation, hypoglycemia, and hyperbilirubinemia and have prolonged acrocyanosis.

A preterm infant of 32 weeks' gestation is admitted from the birth suite to the neonatal intensive care unit with symptoms of respiratory distress. What would the nurse expect to see during assessments? Select all that apply.

pH 7 PaCO2 54 mm Hg PaO2 35 Explanation: The preterm newborn develops atelectasis quickly without alveoli stabilization leading to RDS with hypoxemia, respiratory acidosis, and hypercarbia. This change in the newborn's biochemical environment allows fetal circulation patterns to persist with bradycardia, tachypnea, and hypothermia developing. Respiratory acidosis occurs when the carbon dioxide (PaCO2) is elevated above the normal range (44 mm Hg) leading to a blood pH lower than 7.35. Bradycardia is a heart rate less than 100 bpm. Respiratory rates of 30 breaths per minute are considered worrisome in the newborn. Five minutes after delivery, the PaO2 is approximately 35 to 40, and the oxygen saturation is in the mid 80s.

A nurse is conducting an in-service program for a group of nurses newly hired to work in the labor and birth unit. Part of the program focuses on the neonate and the various mechanisms of heat loss that can occur. Place the mechanisms below in the order that the nurse would describe them as accounting for heat loss from greatest to least. All options must be used.

radiation convection evaporation conduction Explanation: Heat can be lost by four mechanisms including conduction (3%), convection (34%), evaporation (24%), and radiation (39%)

A nurse is explaining to a new mother that her newborn is susceptible to both dehydration and overhydration. The nurse integrates knowledge of which aspect as the underlying mechanism for this risk? Select all that apply.

reduced glomerular filtration rate limited concentration ability Explanation: A full complement of one million nephrons is present by 34 weeks gestation. The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload. Frequently the newborn's kidneys are described as immature, but they are able to carry out their usual responsibilities and can handle the challenge of excretion and maintaining acid-base balance. The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn's kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more.

A nurse is caring for a large-for-gestational age infant whose mother had gestational diabetes. What assessment findings would the nurse be alert for?

ruddy skin color poor feeding facial nerve paralysis tremors Explanation: Infants of diabetic mothers have increased mortality and morbidity, so the nurse must be alert for potential complications. Physical examination of an infant born with a mother diagnosed with gestational diabetes can alert the nurse for signs of possible problems,. The nurse should assess for full rosy cheeks with a ruddy skin color, a short, no-neck appearance, a buffalo hump over the nape of the neck, signs of hypoglycemia with poor feeding, and tremors. The nurse should also assess the LGA newborn for signs of birth trauma.

Which actions should nurses advocate to help the nation achieve the 2020 National Health Goals? Select all that apply.

teaching about folic acid supplementation prior to conception obtaining early prenatal care providing support after the diagnosis of a fetal disorder Explanation: Nurses can help achieve the 2020 National Health Goals by urging women to enter pregnancy with an adequate folic acid level, ensuring women obtain prenatal care, and receive comprehensive advice and support after diagnosis of a fetal or newborn disorder. Frequent sonograms are not necessary, and initiating oral iron supplementation at conception may worsen the nausea and vomiting of early pregnancy.