NU472 Week 2 EAQ Evolve Elsevier: Nursing Care of the Newborn

Which assessment findings signify correct placement of a nasogastric tube into a preterm infant's esophagus for feedings? Select all that apply. o The infant cries without noise. o Aspiration produces a small quantity of light-yellow or light-green liquid. o The tube is inserted to a depth from the ear to the tip of the nose to the sternum. o A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. o Testing of the aspirate with the use of a nitrazine strip reveals that the gastric fluid is acidic.

o Aspiration produces a small quantity of light-yellow or light-green liquid. o Testing of the aspirate with the use of a nitrazine strip reveals that the gastric fluid is acidic. · Aspirated fluid that is either light green or yellow indicates gastric contents. The nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although the tube being inserted to a depth from the ear to the tip of the nose to the sternum is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy? o Stimulates the liver to dispose of the bilirubin o Breaks down the bilirubin into a conjugated form o Facilitates the excretion of bilirubin by activating vitamin K o Dissolves the bilirubin, allowing it to be excreted by the skin

o Breaks down the bilirubin into a conjugated form · Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.

Which early sign of impending hydrocephalus would the nurse monitor for in an infant who has had surgery for repair of a myelomeningocele? o Frequent crying o Bulging fontanels o Change in vital signs o Difficulty with feeding

o Bulging fontanels · After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the initial signs.

Which is prevented by providing warm, humidified oxygen to a preterm infant? o Apnea o Cold stress o Respiratory distress o Bronchopulmonary dysplasia

o Cold stress · By warming and humidifying oxygen, the nurse will prevent cold stress and drying of the mucosa. Apnea and bronchopulmonary dysplasia are not associated with the administration of oxygen that is not warmed or humidified. Respiratory distress can develop in a preterm infant as a result of the cold stress.

The nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). Which would the nurse conclude that these findings indicate? o Hypoglycemia o Seizure activity o Expected adaptations o Respiratory distress syndrome

o Expected adaptations · During periods of active or irregular sleep, healthy newborns have some twitching movements and irregular respirations; the heart rate, respirations, and blood glucose level are within expected limits. Hypoglycemia in newborns is characterized by a blood glucose level below 30 mg/dL (1.7 mmol/L). Twitching is a common finding in healthy neonates and does not indicate seizure activity; it often occurs with crying or stimulation. There are no signs of respiratory distress syndrome. The newborn respiratory rate ranges between 30 and 60 breaths/min; irregular breathing is expected.

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points? o Color: pale o Respiratory rate: slow o Reflex irritability: grimace o Heart rate: 100 beats/min

o Heart rate: 100 beats/min · A heart rate of 100 beats/min or more is the only criterion that rates a 2 on the Apgar score. The pale color rates a 0. A slow respiratory rate or a weak cry rates a 1. A grimace after testing of reflex irritability rates a 1.

When caring for a newly delivered newborn with a heart rate of 76 and gasping, which priority action would the nurse take? o Attempt to clear the airway. o Initiate chest compressions. o Prepare to assist with intubation. o Initiate positive-pressure ventilation.

o Initiate positive-pressure ventilation. · Following the neonatal resuscitation algorithm, the nurse will initiate positive-pressure ventilation and monitor the newborn's SpO2. Clearing the airway delays respiratory support. It is unnecessary to initiate chest compressions or prepare for intubation.

A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. Which condition would the nurse anticipate when assessing this infant? o Prematurity o Cardiac anomalies o Respiratory infection o Intrauterine growth restriction

o Intrauterine growth restriction · The pathological changes of maternal chronic vascular disease cause uteroplacental insufficiency; vasospasms diminish fetal oxygenation and nutrition, which lead to slow fetal growth. Prematurity is defined as gestational age of less than 37 weeks. There is no greater incidence of cardiac anomalies in infants with intrauterine growth restriction. Neither is there a greater incidence of infection in infants with low birth weight; however, they may have a lower resistance to infection.

The nurse is assessing a 12-hour-old newborn. Which clinical finding would be reported to the health care provider in a timely manner? o Jaundice o Cephalhematoma o Erythema toxicum o Edematous genitalia

o Jaundice · 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.

When calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate? o Muscle tone o Amount of mucus o Degree of head lag o Depth of respirations

o Muscle tone · The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score.

Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck? o Nevi o Desquamation o Mongolian spots o Erythema toxicum

o Nevi · Nevi, described as small, flat pink spots, are the result of a superficial capillary defect and are most commonly found on the upper eyelids, nose, upper lip, and nape of the neck. Desquamation is peeling skin that occurs a few days after birth. Mongolian spots are bluish-black areas of pigmentation. Erythema toxicum is a transient rash that appears 24 to 72 hours after birth that can last up to 3 weeks of age.

The nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. Which blood type does the mother usually have to cause this incompatibility? o A o B o O o AB

o O · Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually are not a problem.

Where would the nurse find the area of involvement associated with parietal swelling? o Over the eyes o Behind the ears o At the back of the head o On the top of the skull

o On the top of the skull · The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.

Which adverse effect would the nurse monitor for after administering vitamin K to a newborn? Select all that apply. o Pain o Edema o Jaundice o Erythema o Hemolysis

o Pain o Edema o Jaundice o Erythema o Hemolysis · Adverse reactions associated with vitamin K injections rarely occur, but can include pain at the injection site, edema, and erythema. Jaundice, hemolysis, and hyperbilirubinemia have also been reported, particularly in preterm infants.

While assessing a newborn, the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. Which complication is the nurse concerned about based on these findings? o Polycythemia o Hyperglycemia o Postmaturity syndrome o Respiratory distress syndrome

o Respiratory distress syndrome · The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant; however, there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. Which condition is the nurse concerned about based on these findings? o These findings are expected because infants with this disorder often have some degree of atelectasis. o The inspiratory pressure on the ventilator is probably too low and needs to be increased for adequate ventilation. o These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately. o The endotracheal tube needs to be pulled back to ventilate both lungs because it has probably slipped into the left main stem bronchus.

o These findings indicate that the infant may have a pneumothorax and that the health care provider should be contacted immediately. · Diminution of breath sounds on the right side and detection of PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is being given oxygen by means of positive pressure. These findings are not expected in infants with RDS. A problem with the ventilator will not result in these clinical manifestations. These findings do not indicate that the endotracheal tube has moved.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery with concerns of problems feeding her baby. Which is the probable cause of these feeding difficulties? o Receding jaw o Brain damage o Tongue thrust o Nasal congestion

o Tongue thrust · Tongue extrusion, a reflex response that occurs when the tip of the tongue is touched, is characteristic of infants with Down syndrome and interferes with feeding; this reflex disappears around 4 months of age. A receding jaw does not interfere with suckling. Down syndrome is caused by a chromosomal defect, not brain damage; the feeding problem is related to the chromosomal defect. Nasal congestion is not a characteristic associated with newborns with Down syndrome.

The nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex would the nurse identify? o Moro o Babinski o Tonic neck o Palmar grasp

o Tonic neck · The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month. The Moro reflex is exhibited when a sudden change in equilibrium causes extension and abduction of the extremities followed by flexion and adduction. The Babinski reflex is exhibited when the examiner runs a finger up the lateral (small toe side) undersurface of the foot from the heel to the toes and then across the ball of the foot; the toes separate and flare out in response. The palmar grasp reflex is exhibited when the fingers flex around a person's finger placed in the infant's palm.

Which part of the newborn's foot is the best site to use to obtain blood for the required newborn metabolic testing? o Big toe o Foot pad o Inner sole o Outer heel

o Outer heel · The outer heel is the preferred site to obtain blood because it is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.

Which statement by the nurse indicates an understanding of anatomic birth injuries? Select all that apply. o "Cephalhematoma is a skull injury." o "Caput succedaneum is a scalp injury." o "Cerebellar contusion is a plexus injury." o "Diaphragmatic paralysis is a cranial nerve injury." o "Epidural hematoma is a cervical spinal cord injury."

o "Caput succedaneum is a scalp injury." · Caput succedaneum is a scalp injury. Cephalhematoma is an injury to the scalp, not the skull. Cerebellar contusion is an intracranial, not a plexus, injury. Diaphragmatic paralysis results from injury to the plexus, not a cranial nerve. Epidural hematoma is an intracranial injury, not an injury of the cervical spine.

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? o "We'll have to start serial casting right away." o "The casts will have to be changed every week." o "The baby may have to have surgery if the problem is not fixed in a few months." o "We'll have to have the baby fitted with prosthetic devices before the baby is able to walk."

o "We'll have to have the baby fitted with prosthetic devices before the baby is able to walk." · Prosthetic devices are generally not needed for this condition. If parents make this statement, they require further teaching. Serial casting with weekly cast changes is the typical treatment for this condition and is usually successful. Surgery may be needed if the serial casting is not effective, therefore those statements indicate that parents understand the treatment plan.

How would an Apgar score recorded 5 minutes after birth assist the nurse in evaluating the care of the newborn? o Gestational age of the newborn o Effectiveness of the birthing process o Possibility of respiratory distress syndrome o Adequacy of the transition to extrauterine life

o Adequacy of the transition to extrauterine life · The score at 5 minutes indicates the adequacy of the cardiac and respiratory systems' response to the environment. The Dubowitz score is related to gestational age. The Apgar score represents the neonate's response to the environment and is not related to the actual process of labor and birth. The Apgar score is not a diagnostic tool for respiratory distress syndrome.

While teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her baby through the placenta? o Active natural o Passive natural o Active artificial o Passive artificial

o Passive natural · Passive natural immunity is developed from an antigen-antibody response in the mother that is transmitted to the fetus. Active natural immunity is acquired by an individual in response to a disease or an infection. Active artificial immunity is acquired by an individual in response to small amounts of antigenic material (e.g., vaccination). Passive artificial immunity is conferred by the injection of antibodies prepared in another host.

Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? o Duration of cry o Respiratory distress o Frequency of voiding o Poor nutritional intake

o Respiratory distress · Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. If the infant is in respiratory distress, the nutritional intake is not important.