OB Chp 19 & 20
The nurse is educating the parents of a newborn who has been diagnosed with true breast milk jaundice. Which instructions will the nurse include in the education? 1 "The newborn should have eight to 12 feedings in a 24-hour period." 2 "The newborn should be given at least 15 mL of glucose water daily." 3 "There is no intervention necessary; the jaundice will resolve on its own." 4 "The newborn will be supplemented with formula until the bilirubin decreases."
1 Parent education for the treatment of true breast milk jaundice will include close monitoring of the total serum bilirubin and the maintenance of eight to 12 feedings per 24-hour period to promote the excretion of bilirubin. Glucose water is not recommended and will not decrease the bilirubin levels. Intervention is necessary to promote excretion of bilirubin. Supplementation with formula is unnecessary unless the bilirubin level becomes dangerously high
In planning interventions to prevent cold stress in the newborn, which methods of heat loss will the nurse consider? Select all that apply. 1 Radiation 2 Frequency 3 Evaporation 4 Conduction 5 Convection
1,3,4,5 The methods of newborn heat loss include radiation, evaporation, conduction, and convection. Frequency is not a method of heat loss in a newborn.
In which digestive enzymes are newborns deficient? Select all that apply. 1 Lipase 2 Protease 3 Peptidase 4 Salivary amylase 5 Pancreatic amylase
1,5 Newborns are deficient in both lipase, which helps with some digestion of fat, and pancreatic amylase, which is needed for the digestion of complex carbohydrates. Newborn infants are not deficient in protease or peptidase, which help to digest protein, or salivary amylase, which starts the breakdown of carbohydrates in the mouth.
What type of heat transfer keeps an infant warm when exposed to circulating air in an incubator? 1 Radiation 2 Convection 3 Conduction 4 Evaporation
2 Convection is the transfer of heat that keeps an infant warm because of circulating air in an incubator; it is the transfer of heat from the infant to the cooler surrounding air that keeps the air warm in an incubator. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. Conduction occurs if an infant is placed on an object that is cooler than the skin, such as a scale. Evaporation occurs with air-drying of the skin.
Which factors can cause excessive production of bilirubin or interfere with the normal process of conjugation? Select all that apply. 1 Cold stress 2 Polycythemia 3 Female gender 4 Delayed feeding 5 Caucasian ethnicity 6 Trauma during birth
1,2,4, 5 Cold stress, polycythemia, delayed feeding, and trauma during birth are all factors that might cause excessive production of bilirubin or interfere with the normal process of conjugation. Males are more likely to have hyperbilirubinemia. Asian, American Indian, and Native Alaskan infants are more likely than Caucasian infants to have hyperbilirubinemia.
Which factors contribute to the cause and continuation of a newborn's respiratory effort after birth? Select all that apply. 1 Sensory 2 Chemical 3 Biological 4 Mechanical 5 Thermal
1,2,4,5 The factors that contribute to the cause and continuation of the respiratory effort of the newborn are sensory, chemical, mechanical, and thermal. A biological factor does not contribute to the cause and continuation of the respiratory effort of a newborn.
What environmental temperature provides a thermoneutral zone for a healthy, unclothed, full-term newborn? 1 72.1°F 2 82.1°F 3 92.1°F 4 102.1°F
2 The thermoneutral range is from 89.6°F to 92.3°F, so 92.1°F is within that range. The temperatures 72.1°F and 82.1°F are too low, and 102.1°F is too high.
What is true of individual immunoglobulins (Ig)? Select all that apply. 1 IgM crosses the placenta. 2 IgM helps protect against Gram-negative bacteria. 3 IgA is important in protection of the gastrointestinal and respiratory systems. 4 IgA is the first immunoglobulin to be produced when the newborn's immune system is challenged. 5 IgG provides the fetus with passive temporary immunity to bacteria, bacterial toxins, and viruses to which the mother has developed immunity.
2,3,5 IgM helps protect against Gram-negative bacteria. IgA is important in protection of the gastrointestinal and respiratory systems. IgG provides the fetus with passive temporary immunity to bacteria, bacterial toxins, and viruses to which the mother has developed immunity. IgM is too large to cross the placenta. IgM, not IgA, is the first immunoglobulin to be produced when the newborn's immune system is challenged.
At the time of discharge, the nurse performs a routine screening of the neonate. On assessing the results, the nurse observes that pulse oximetry is 96% in the infant's right foot, with a 1% difference between the right hand and the right foot. Which is the best statement to be given to the parents? 1 "We need to repeat the screening in 1 hour." 2 "We need to repeat the screening twice more." 3 "We need to screen the infant using echocardiography." 4 "No further testing is needed for the infant."
4 Pulse oximetry is performed as part of the routine screening for critical congenital heart disease within 24 hours of birth or before the discharge of the neonate. Pulse oximetry of 96% (above 95%) in the right foot and a 1% (less than 3%) difference between the right hand and the right foot indicates a negative screening. Therefore, no further testing is needed. Pulse oximetry of 90% to 95% in the right hand or foot, or more than 3% difference between the two extremities, requires the test to be repeated in 1 hour. If screening values remain the same as the first time, the screening is repeated again; if unchanged, it indicates a positive screening. Pulse oximetry of less than 90% in the right hand or foot is considered a positive screening, which indicates the need for additional testing such as an echocardiogram.
When caring for a newborn, what is a sign of cold stress the nurse should anticipate? 1 Decreased activity level 2 Increased respiratory rate 3 Hyperglycemia 4 Shivering
2 An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.
How much fluid does a newborn weighing 7 lb need in the first 3 to 5 days of life? 1 130 mL 2 252 mL 3 420 mL 4 630 mL
2 Full-term infants need 60 to 100 mL/kg (27 to 45 mL/lb) daily for the first 3 to 5 days of life. A 7-lb infant therefore needs 252 mL. Intake of 130 mL is not adequate. Intakes of 420 mL and 630 mL are excessive based on the infant's weight.
A neonate's bloodwork shows an elevated number of immature leukocytes and decreased platelets. What is the most likely explanation? 1 Internal bleeding 2 Infection or sepsis 3 Clotting deficiency 4 Respiratory distress
2 In a neonate, an increased number of immature leukocytes and decreased platelets indicate infection or sepsis. Internal bleeding, clotting deficiency, and respiratory distress do not cause elevated levels of immature leukocytes or decreased platelets.
The nurse is caring for a neonate in the nursery. What behavior in the neonate does the nurse recognize as thermogenesis? 1 Starts shivering incessantly 2 Assumes position of extension 3 Cries and appears restless 4 Develops pallor and seizures
3
Which statements will a nurse make when educating new parents about a newborn's immune system? Select all that apply. 1 "Newborns usually run a fever with infections." 2 "Newborns have a decreased risk of generalized sepsis." 3 "Newborns have a decreased ability to localize infection." 4 "The leukocytes in newborns are efficient at destroying invaders." 5 "Full-term infants receive antibodies from their mothers during the last trimester of pregnancy."
3,4 Newborns have a decreased ability to localize infections. Full-term infants receive antibodies from their mothers during the last trimester of pregnancy. Fever is often not present in newborns with infection. Because newborns have a decreased ability to localize infection, they have an increased risk of generalized sepsis. The leukocytes in newborns are inefficient at destroying invaders.
The nurse is assessing a newborn for the presence of seizure activity. What action by the newborn does the nurse document as a sign of seizure activity? 1 Tremor is easily elicited by a sound or motion. 2 Tremor ceases with gentle restraint of the extremity. 3 Tremor reduces or stops with passive flexion. 4 Tremor is accompanied by ocular changes.
4 Tremors accompanied by ocular changes such as deviating or staring eyes are not normal in newborns and are a symptom of seizure activity. It is normal for a newborn to tremor when a sound is heard or when there is a slight motion. The tremor ceases with gentle restraint of the extremity by the caregiver. It is normal for the tremors to stop when the extremity is flexed passively by the caregiver
The nurse is reviewing a newborn's bloodwork, in which it is noted that the sample was taken from the heel. Compared to blood samples taken from central areas, blood samples drawn from an infant's heel are higher in which blood components? Select all that apply. 1 Calcium 2 Glucose 3 Leukocytes 4 Hematocrit 5 Hemoglobin 6 Erythrocytes
4,5,6 Compared to blood samples taken from central areas, blood samples drawn from an infant's heel are higher in hematocrit, hemoglobin, and erythrocytes. Blood samples drawn from the heel are not higher in calcium, glucose, or leukocytes.
Which initial assessment finding is typical of a newborn experiencing cold stress? 1 Jaundice 2 Hypoglycemia 3 Polycythemia 4 Ineffective use of brown fat
An initial finding for a newborn experiencing cold stress is hypoglycemia. As the newborn's metabolic rate increases due to the decreased body temperature, the newborn's use of glucose and oxygen consumption increases. Jaundice does not occur initially in the newborn experiencing cold stress. Polycythemia occurs in relation to an increased production of red blood cells. The newborn experiencing cold stress utilizes the brown fat stores to help produce heat and maintain body temperature.
The nurse is assessing a newborn and notes skin pallor. What order does the nurse anticipate from the provider? 1 Blood draw for a complete blood count (CBC) 2 Placing newborn under warmer for 1 to 2 hours 3 Monitoring vital signs every 2 hours until pallor subsides 4 Supplementing breastfeeding with a bottle of formula
1 Pallor in a newborn can indicate hypoxia or anemia. The provider would likely order a CBC in order to assess hemoglobin or hematocrit levels. Placing an infant under the warmer will not address underlying hypoxia or anemia. Monitoring vital signs every 2 hours is not appropriate because conditions of hypoxia should be taken care of promptly. Supplementing breastfeeding with formula does not address hypoxia or anemia.
What is true of surfactant? 1 It is a combination of lipoproteins. 2 It is detectable by 12 weeks of gestation. 3 It increases the surface tension within alveoli. 4 Its secretion decreases during labor and immediately after birth
1 Surfactant is a slippery, detergent-like combination of lipoproteins. It is not detectable until 24 to 25 weeks of gestation. Surfactant decreases the surface tension within alveoli. Surfactant secretion increases during labor and immediately after birth to enhance the transition from fetal to neonatal life.
What is a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? 1 Apical heart rate of 90 beats/minute, slightly irregular, when awake and active 2 Acrocyanosis 3 Harlequin color sign 4 Weight loss representing 5% of the newborn's birth weight
1 The heart rate of a newborn should range from 120 to 140 beats/minute, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.
The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report? 1 The ability to suck 2 Head circumference 3 Abdominal movements 4 Head-to-toe measurements
1 The neurologic assessment of neonates is performed by determining reflex behaviors, such as sucking, rooting, and grasping. The head circumference and the body measurements indicate the physical growth of a neonate. The neonate's abdominal movements are related to the respiratory rate and do not relate to the neonate's neurologic activity.
While placing a newborn under a radiant warmer, the nurse observes the infant averting his or her gaze from the overhead lights. Which statement best describes the nurse's observation of the newborn's behavior? 1 The newborn is displaying habituation. 2 The newborn is in the first period of reactivity. 3 The newborn is in the second period of reactivity. 4 The newborn is displaying the ability to self-console.
1 The newborn who averts his or her gaze from the lights is displaying habituation. Habituation is the infant's response to the stimulus from the overhead lighting of the warmer. During the first and second periods of reactivity, newborns cannot be awakened easily and are not interested in feeding. The newborn who demonstrates the ability to self-console may bring his or her hands to the mouth, sucking on the fists, listening to voices, and watching objects in the environment.
During an assessment, the nurse notes a newborn's eyes appear glazed and unfocused. The newborn moves all extremities slowly and then returns to sleep. The nurse understands that the newborn is displaying which behavioral state? 1 Drowsy state 2 Light sleep state 3 Quiet sleep state 4 First period of reactivity
1 The newborn whose eyes appear glazed and unfocused and who is moving all extremities slowly and then returning to sleep is displaying the drowsy behavioral state. During the period of a light sleep state, the newborn will move his or her extremities, stretch, change facial expressions, make sucking movements, and may fuss briefly. During the quiet sleep state, the infant is in a deep sleep with closed eyes and no eye movements. The first period of reactivity is one of the two periods of reactivity in the early hours after birth.
The nurse is observing a student nurse perform an assessment of the fontanels. Which action by the student requires immediate intervention? 1 Holding the infant supine during palpation 2 Palpating the fontanels while the infant is quiet 3 Palpating for both the anterior and posterior fontanels 4 Feeling for the anterior fontanel at the connection of the frontal and parietal bones
1 The nurse should assess the fontanels while the infant is sitting or held upright for accurate assessment. The infant should not be placed supine for this assessment. The infant should be quiet and calm during the assessment because vigorous crying can alter the fontanels. The nurse should palpate for both the posterior fontanels (at the junction of the occipital and parietal bones) and the anterior fontanels (where the frontal and parietal bones meet).
What findings might the nurse expect in a neonate within 30 minutes of birth? Select all that apply. 1 Retractions 2 Nasal flaring 3 Audible grunting 4 Pinkish skin color 5 Quick respiration
1,2,3 The first 30 minutes after birth is referred to as the first period of reactivity. Tremors, nasal flaring, and grunting are the signs seen in this phase. These signs disappear within the first hour of birth. Pinkish skin color and quick, shallow respirations are not observed immediately after the birth; they are observed in the period of decreased responsiveness, which occurs around 60 to 100 minutes after the first period of reactivity.
What is true of the newborn infant's intestines? Select all that apply. 1 The digestive tract is sterile at birth. 2 Bowel sounds will be heard beginning at 15 minutes after birth. 3 Normal intestinal flora isn't established until the 2nd or 3rd month of life. 4 The intestines of a newborn are short in proportion to the infant's size and as compared to an adult's. 5 Infants are more prone to water loss with diarrhea because of their comparatively long intestines.
1,2,5 The digestive tract is sterile at birth; once the infant is exposed to the external environment and begins to take in fluid, bacteria enter the gastrointestinal tract. Bowel sounds should be heard beginning at 15 minutes after birth. Infants are more prone to water loss with diarrhea because of their comparatively long intestines. The intestines of a newborn are longer in proportion to the infant's size and as compared to an adult's. Normal intestinal flora is established within the first few days of life.
The newborn's nurse knows which newborn reflex assessment findings are normal? Select all that apply. 1 Newborn turns head toward stimulus with mouth open when eliciting rooting reflex. 2 Newborn's fingers fan out when palmar reflex checked. 3 Newborn forces tongue outward when tongue touched. 4 Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. 5 Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.
1,3,4,5 When eliciting the rooting reflex, the characteristic response is for the baby to turn its head toward the stimulus and open its mouth. Extrusion is elicited by touching the tongue, and the newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers forming a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe. The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex.
What maternal conditions may cause accelerated lung maturation in a fetus? Select all that apply. 1 Infection 2 Diabetes 3 Placental insufficiency 4 Preeclampsia 5 Hypertension 6 Heroin addiction
1,3,4,5,6 Lung maturation may be accelerated in infants born to mothers with infection, placental insufficiency, preeclampsia, hypertension, and/or heroin addiction. Infants born to women with diabetes often have slower lung maturation.
Which problems should the nurse be most concerned about if a newborn develops nonphysiologic jaundice? Select all that apply. 1 Infection 2 Insufficient intake 3 Metabolic disorders 4 Delayed elimination of meconium 5 Incompatible mother and infant blood type
1,3,5 Causes of nonphysiologic jaundice include infection, metabolic disorders, and incompatibility of mother and the infant blood types. The most common cause of early onset jaundice is insufficient intake. In early onset jaundice, infants who are sleepy, have a poor suck, or nurse infrequently may not benefit from the laxative effect of colostrum, resulting in delayed elimination of meconium.
Where is brown fat located? Select all that apply. 1 Axillae 2 Calves 3 Back of the neck 4 Soles of the feet 5 Around the liver 6 Between the scapulae
1,3,6 Brown fat is located in the axillae, the back of the neck, and between the scapulae. It is also located around the heart, kidneys, adrenals, and along the abdominal aorta. There is no brown fat in the calves, the soles of the feet, or around the liver.
What signs typically indicate that an infant is cold? Select all that apply. 1 Crying 2 Shivering 3 Drowsiness 4 Restlessness 5 Decreased activity
1,4 A cold infant will typically cry and become restless. Newborns rarely shiver except during prolonged exposure to low temperatures. Newborns do not become drowsy or display decreased activity when cold; rather, they become agitated. Their increased activity and flexion help generate some warmth and reduce the loss of heat from exposed surface areas of the body.
Which conditions may reverse the pressures in the heart and cause the foramen ovale to reopen? Select all that apply. 1 Asphyxia 2 Metabolic acidosis 3 Clotting deficiencies 4 Pulmonary hypertension 5 Decreased surfactant production
1,4, Both asphyxia and pulmonary hypertension might cause a reversal of pressures in the heart and a reopening of the foramen ovale. Metabolic acidosis, clotting deficiencies, and decreased surfactant production do not play a role in the reopening of the foramen ovale
What is true of blood glucose homeostasis in newborn infants? Select all that apply. 1 Glycogen stores are almost depleted within 12 hours after birth. 2 Postterm infants often have high blood glucose concentrations at birth. 3 Glucose levels commonly fall to the lowest levels about 3 hours after birth. 4 An infant born at term should have glucose in the range of 40 to 60 mg/dL on the first day. 5 Infants who are large for gestational age and those with diabetic mothers may have hypoglycemia.
1,4,5 Glycogen stores are almost depleted within 12 hours after birth. Infants born at term should have glucose levels 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. Infants who are large for gestational age and those with diabetic mothers may produce excessive insulin that consumes available glucose quickly. Glycogen stores may be depleted before birth in the postterm infant because of poor intrauterine nourishment from a deteriorating placenta; therefore, postterm infants often have low blood glucose concentrations at birth. Glucose levels commonly fall to their lowest levels 60 to 90 minutes after birth but rise and stabilize 2 to 3 hours after birth.
Which type of heat transfer occurs when an infant is placed on a scale to be weighed? 1 Radiation 2 Convection 3 Conduction 4 Evaporation
2 Conduction occurs if an infant is placed on an object that is cooler than the skin, such as a scale. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. Convection is the transfer of heat from an infant to cooler surrounding air. Evaporation occurs with air-drying of the skin.
he nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse if something is wrong. What is an appropriate response to this mother's concern? 1 Telling the mother not to worry because all breastfed babies have this type of stool 2 Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns 3 Asking the mother what she ate for her last meal 4 Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her
2 The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark-green to black color. At this early age this type of stool is typical of both bottle- and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of a meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.
The nurse is assessing the vital signs of a neonate 12 hours after birth. Which method should the nurse use to check the infant's temperature? 1 Rectal route 2 Axillary route 3 Temporal artery 4 Tymphanic route
2 The nurse must assess the neonate's temperature using the axillary route. This method is a safe and accurate measurement of temperature. Rectal temperatures should not be obtained for a neonate because there is a risk of perforation. Temperature is not assessed by the temporal artery or tympanic route in the newborn, because the result of this measurement is considered inaccurate.
A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? 1 Place the newborn in incubator. 2 Administer ophthalmic solution. 3 Perform a heelstick puncture test. 4 Provide ventilator support to the newborn.
2 The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/minute. However, the heart rate is not decreased due to gonorrheal infection.
What care should the nurse take while performing a heelstick for the infant? 1 Puncture the inner aspect of the heel. 2 Warm the heel before taking the sample. 3 Ensure the puncture is no deeper than 1 mm. 4 Apply pressure for a minute after the procedure.
2 The nurse should warm the heel by applying heat for 5 to 10 minutes. The warmth helps to dilate the vessels in the area. The nurse should puncture the outer aspect of the heel to prevent injury by drawing an imaginary line from between the fourth and fifth toes to the heel and parallel to the lateral aspect of the foot. The puncture should be no deeper than 2.4 mm to prevent bone injury, which may lead to necrotizing osteochondritis. After collection of the blood sample, the nurse should only apply gentle pressure with a dry gauze pad and cover it with an adhesive bandage.
The nurse is assessing an 8-hour-old neonate's head. The nurse palpates an area of localized edema over the left parietal region and notes that the edema ends at the edge of the suture line. Based on the assessment finding, what will the nurse include in the plan of care for the neonate? 1 Right lateral positioning 2 Careful monitoring for jaundice 3 Frequent neurological assessments 4 Frequent assessment of head molding
2 The nurse will include frequent monitoring for jaundice in the plan of care for the neonate. The assessment findings indicate the neonate has a cephalohematoma, which is a collection of blood between the periosteum and the skull. Because of the breakdown of the red blood cells within the hematoma, affected infants are at greater risk for jaundice. The infant should not be placed in a right lateral position. Frequent neurological assessments are not necessary. Head molding and the presence of a cephalohematoma are unrelated.
The nurse is caring for a newborn delivered by a mother with type I diabetes. The mother asks, "Why do you have to test my baby's blood glucose?" Which response by the nurse provides the most accurate information to the mother? 1 "The placenta has deteriorated, so the baby is at risk for hypoglycemia." 2 "The baby produces insulin and is no longer receiving glucose from you." 3 "Your baby is at risk for high blood sugar due to your diabetic condition." 4 "All newborns born to diabetic mothers will have their blood glucose tested."
2 The response that provides the most accurate information is, "The baby produces insulin and is no longer receiving glucose from you." The newborn produces insulin in relation to maternal glucose when in utero. When the baby is born and the umbilical cord is cut, the newborn no longer receives maternal glucose but may have produced excess insulin that quickly consumes glucose stores. The placenta deteriorates in postterm pregnancies and other conditions. The newborn is not at risk for hyperglycemia due to maternal diabetes. The statement "All newborns born to diabetic mothers will have their blood glucose tested" does not answer the patient's question.
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as what? 1 Tonic neck reflex 2 Moro reflex 3 Cremasteric reflex 4 Babinski reflex
2 These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.
The nurse is caring for an infant with breathing difficulty. Upon auscultating the infant, the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care? 1 "Use formula milk." 2 "Additional cardiac testing is necessary." 3 "The infant should be wrapped in a thick blanket." 4 "Maintain skin-to-skin contact with the mother."
2 Typically, the presence of cardiac murmurs in infants has no pathologic significance. However, when murmurs are associated with other conditions, such as breathing difficulty, which may cause apnea and cyanosis, they are considered abnormal. In this case the primary health care provider will send the child for cardiac testing to diagnose any more serious condition. While skin-to-skin contact is useful in enhancing thermoregulation in infants, it will not have any effect on heart murmurs. Wrapping the infant in a thick blanket prevents cold distress in the infant, but does not affect the cardiac murmur. Feeding the infant with formula milk is unrelated to cardiac murmurs.
A nurse is explaining to new parents what happens after the umbilical cord is clamped as the newborn's circulatory system transitions from the fetal state. The nurse states that blood flow in the umbilical vessels permanently become obstructed at what point? 1 At birth 2 Within 1 to 2 weeks 3 Within 4 to 6 weeks 4 Within 8 to 10 weeks
2 Umbilical vessels permanently become obstructed of blood flow within 1 to 2 weeks. At birth is too early; the obstruction becomes functional when the umbilical cord is clamped but not permanent. The transition is complete before 4 to 6 or 8 to 10 weeks.
What is true of immunoglobulin G (IgG) in infancy? Select all that apply. 1 IgG does not cross the placenta. 2 Preterm infants have less IgG than full-term infants. 3 Full-term infants have higher levels of IgG than their mothers. 4 Significant production of IgG is delayed until after 6 months of age. 5 The passive immunity from IgG is at its highest level at 2 to 4 months of age.
2,3,4 Preterm infants have less IgG because transfer is greatest during the third trimester. The full-term infant has IgG levels that are as high as or higher than those of the mother. Although the fetus makes some IgG, significant production of IgG is delayed until after 6 months of age. It is not true that IgG does not cross the placenta; IgG is the only immunoglobulin that crosses the placenta. Passive immunity from IgG gradually disappears and reaches the lowest level at 2 to 4 months of age.
The nurse is caring for a healthy Caucasian neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? 1 Bluish-black areas on the body 2 Desquamation of the epidermis 3 Vernix caseosa covering the body 4 Dark red-colored swellings on the body
3 After 35 weeks of gestation the newborn's body gets covered with vernix caseosa, which resembles a cheesy white substance and is fused with the epidermis of the skin. It is formed to protect the fetus' skin from the contents of the uterus. Postdate fetuses lose the vernix caseosa and the epidermis may become desquamated. Desquamation (peeling) of the skin occurs a few days after birth. Mongolian spots are characterized by bluish-black pigmentation of the skin, and are generally observed in Mediterranean, Latin American, Asian, or African newborns. They are not usually observed in European newborns. A nevus vascularis is a common type of capillary hemangioma, in which the infant develops dark red-colored swellings. Because the child is healthy, the nurse will not find dark red-colored lesions on the body.
In most healthy newborns, blood glucose levels stabilize at what mg/dL during the first hours after birth? 1 80 to 100 2 Less than 40 3 40 to 60 4 60 to 70
3 In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first several hours after birth. This is the normal plasma glucose level in the adult. A blood sugar level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life the blood glucose levels should be approximately 60 to 70 mg/dL.
Obstruction should be suspected if an infant does not pass meconium within how many hours of birth? 1 12 hours 2 24 hours 3 48 hours 4 72 hours
3 Obstruction should be suspected if meconium is not passed within 48 hours. It is normal for an infant to not pass meconium at 12 or 24 hours. Obstruction should be suspected before 72 hours have passed.
The nurse is performing a Ballard assessment on a neonate suspected to be at 24 weeks of gestation. Which finding is contradictory to the suspected gestational age? 1 180-degree arm recoil 2 Poor flexor tone 3 Anterior plantar creases 4 Sparse amount of lanugo
3 Plantar creases begin to appear at 28 to 32 weeks of gestation and cover the entire foot by term. A 180-degree arm recoil, poor flexor tone, and a sparse amount of lanugo are common findings in a preterm neonate who is at approximately 24 weeks of gestation.
Why is Vitamin K is given to the newborn? 1 To reduce bilirubin levels 2 To increase the production of red blood cells 3 To enhance the ability of blood to clot 4 To stimulate the formation of surfactant
3 Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K does not stimulate the formation of surfactant.
The nurse observes that an infant exhibits grunting and nasal flaring. The infant also has a low respiratory rate. What intervention should the nurse follow to prevent aspiration of mucus in the infant? 1 Place the infant in the Trendelenburg position. 2 Expose the infant to cool air and drafts. 3 Administer total parenteral nutrition (TPN) as prescribed. 4 Place the infant in prone position and avoid neck hyperextension.
4 Grunting, nasal flaring, and low respiratory rate indicate an ineffective respiratory pattern related to pulmonary activity in the infant. Therefore, the nurse has to place the infant in the prone or supine position without hyperextending the infant's neck. This helps the infant breathe more comfortably. The Trendelenburg position is avoided to prevent increased intracranial pressure and reduction of lung capacity. Exposure to cool air and drafts is avoided to prevent predisposition of the infant to heat loss. TPN is administered as prescribed to provide the infant with adequate nutrition and fluid intake.
The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition? 1 A body weight of 7 pounds 2 A heart rate 120 beats/minute 3 A head-to-heel length of 55 cm 4 A head circumference greater than chest circumference
4 Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/minute indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.
The nurse is caring for a group of newborns in the nursery and is reviewing the morning vital signs. The newborn with which presentation requires priority assessment? 1 A 5-second pause in breathing 2 Respiratory rate of 42 breaths/minute 3 Shallow respirations of 58 breaths/minute 4 A 20-second pause in breathing with cyanotic lips
4 Periods of apnea, cessation of breathing lasting 20 seconds or more with cyanosis, pallor, bradycardia, or decreased muscle tone, is an abnormal finding and requires immediate assessment by the nurse. A 5- to 10-second pause in newborn infants, especially premature newborns, does not require priority assessment. A normal respiratory rate in infants is 30 to 60 breaths/minute that are shallow and rapid.
The nurse is caring for a neonate immediately after birth. Which finding would require the nurse to notify the primary health care provider during the first 2 days after birth? 1 The neonate's diaper has pink-tinged stains. 2 The neonate's urine is cloudy after the first voiding. 3 The neonate voids eight times during the day. 4 The neonate has not voided for 24 hours.
4 The nurse must notify the primary health care provider if the neonate has not voided for 24 hours. The neonate should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain. Pink-tinged stains in the diaper indicate the presence of uric acid crystals in the urine. It is normal during the first week; however, later on it can be a sign of inadequate intake. It is normal for the urine to appear cloudy after the first voiding, due to the presence of mucus. Six to eight voidings per day of pale, straw-colored urine indicate adequate fluid intake; this frequency is not a cause for concern.
What will a newborn male, estimated to be 39 weeks of gestation, exhibit? 1 Testes descended into the scrotum 2 Extended posture when at rest 3 Abundant lanugo over his entire body 4 Ability to move his elbow past his sternum
1 A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion. A term infant's good muscle tone results in a more flexed posture when at rest. A full-term infant exhibits only a moderate amount of lanugo, usually on the shoulders and back. Preterm infants have an abundance of lanugo over the entire body. The muscle tone of a full-term newborn prevents him from being able to move his elbow past midline.
The nurse is assessing a neonate immediately after birth. How does the nurse document the presence of bluish-black pigmentation on the neonate's buttocks? 1 Mongolian spots 2 Nevus simplex 3 Nevus flammeus 4 Erythema toxicum
1 Mongolian spots are bluish-black areas of pigmentation on the neonate's back. This information must be documented because they can be mistaken for bruises after discharge, raising the suspicion of physical abuse. Nevi simplex are usually small, flat, pink lesions that are easily blanched. The most common sites are the upper eyelids, nose, upper lip, and nape of the neck. Nevus flammeus, or a port-wine stain, is usually pink and flat at birth, but darkens with time, turning red or purple and becoming pebbly in consistency. Erythema toxicum is a transient rash that first appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks.
A woman is in preterm labor. What intervention will most likely help to increase surfactant production and speed maturation of the infant's lungs? 1 Providing a steroid 2 Providing a diuretic 3 Providing glucagon 4 Providing human growth hormone
1 Provision of a steroid to a woman in preterm labor might help increase surfactant production and speed maturation of the infant's lungs. Diuretics, glucagon, and human growth hormone are not used for these purposes.
With regard to the respiratory development of the newborn, of what should nurses be aware? 1 Crying increases the distribution of air in the lungs. 2 Newborns must expel the fluid in utero from the respiratory system within a few minutes of birth. 3 Newborns are instinctive mouth-breathers. 4 Seesaw respirations are no cause for concern in the first hour after birth.
1 Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, which helps draw air into the lungs. The positive pressure created by crying helps to keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose-breathers; they may not have the mouth breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.
What may interfere with an infant's ability to use brown fat to generate heat? Select all that apply. 1 Hypoxia 2 Acidosis 3 Jaundice 4 Hypoglycemia 5 Metabolic acidosis
1,2,4 Hypoxia, acidosis, or hypoglycemia might interfere with an infant's ability to use brown fat to generate heat. Jaundice and metabolic acidosis do not interfere with an infant's ability to use brown fat. However, the metabolism of brown fat releases fatty acids, which can result in metabolic acidosis and consequently increase the risk for jaundice.
Which structure in fetuses provides a flap valve between the right atrium and left atrium so blood can bypass the nonfunctioning lungs and go directly to the left ventricle and aorta? 1 Foramen ovale 2 Ductus venosus 3 Ductus arteriosus 4 Pulmonary blood vessels
1 The foramen ovale provides a flap valve between the right atrium and left atrium so blood can bypass the nonfunctioning lungs and go directly to the left ventricle and aorta. The ductus venosus shunts one-third of the blood from the umbilical vein to the inferior vena cava and away from the immature liver. The ductus arteriosus is widely dilated to carry blood from the pulmonary artery to the aorta, avoiding the nonfunctioning lungs. The pulmonary blood vessels are narrowed vessels that increase resistance to the blood flowing to the lungs.
A newborn has physiologic jaundice, and his or her mother asks the nurse when it will resolve. How does the nurse respond? 1 "It will resolve in 2 to 3 days." 2 "It will resolve in 5 to 7 days." 3 "It will resolve in 8 to 10 hours." 4 "It will resolve in 24 to 48 hours."
2 In a newborn with physiologic jaundice, bilirubin levels will peak between the 2nd and 4th days of life and fall to normal within 5 to 7 days. The process takes longer than 2 to 3 days, 8 to 10 hours, or 24 to 48 hours.
What does the nurse know is the risk of chronic accumulation of unconjugated bilirubin in an infant's blood? 1 Jaundice 2 Kernicterus 3 Bilirubin encephalopathy 4 Destruction of red blood cells
2 Kernicterus, a permanent neurological injury, is associated with chronic accumulation of unconjugated bilirubin in the blood. Jaundice results from hyperbilirubinemia. It occurs in 60% of term newborns and 80% of preterm infants; however, it is not a chronic condition. Bilirubin encephalopathy is the acute result of unconjugated bilirubin accumulating in the blood and staining the tissues of the brain; it is not a chronic condition. Physiologic destruction of red blood cells is a source of bilirubin; it is not a result of chronic accumulation of unconjugated bilirubin.
What is a normal urine output for a 7-lb newborn? 1 4 mL/hr 2 14 mL/hr 3 24 mL/hr 4 34 mL/hr
2 Normal urine output is 2 to 5 mL/kg/hour. For a 7-lb newborn, appropriate output is between 6.4 and 15.9 mL/kg/hour. Therefore, 14 mL/hr is normal. An output of 4 mL/hr is too low to be normal. Outputs of 24 and 34 mL/hr are higher than the normal range.
What is the examiner's action who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver? 1 Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking 2 Alerts the physician that the infant has a dislocated hip 3 Informs the parents and physician that molding has not taken place 4 Suggests that if the condition does not change, surgery to correct vision problems might be needed
2 The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. "One leg may be longer than the other, but they will equal out by the time the infant is walking" is an inappropriate statement that may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn.
A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? 1 Jaundice appeared within the first 24 hours of life. 2 Jaundice appeared on the third day of life. 3 A preterm infant is 12 hours old. 4 The infant is being bottle fed within the first 24 hours of life.
2 The normal respiratory rate for a neonate is 30 to 60 breaths/minute. The infant may breathe faster immediately after birth and may exhibit a pattern of irregular respirations. The finding the nurse can anticipate in a neonate born 15 minutes prior are rapid, irregular respirations with a rate of 56 breaths/minute. Slow, deep respirations with a rate of 42 breaths/minute is not an expected finding in the 15-minute-old newborn. A pause in breathing lasting 20 seconds is considered apnea. A respiratory rate of 64 breath/minute is outside the normal parameters.
At what age should a nurse advise the parents of a breastfed infant to begin to give the baby either iron-containing foods or iron supplements? 1 At birth 2 At 1 year 3 At 6 months 4 When the infant stops breastfeeding
3 Breastfed infants should begin to receive iron-containing foods or iron supplements at 6 months of age. At birth is too early, and at 1 year is too late. Infants stop breastfeeding at various ages; therefore, this is not an adequate recommendation.
The nurse is examining the external genitalia of a female infant. What finding must the nurse report? 1 Slight bloody spotting 2 Presence of hymenal tag 3 Mucoid vaginal discharge 4 Fecal discharge from vagina
4 Fecal discharge from the vagina indicates a rectovaginal fistula. This finding should be reported to the neonatal nurse practitioner for further evaluation. Slight bloody spotting, or pseudomenstruation, is normal and need not be reported. Nearly all female infants are born with hymenal tags. The nurse must report the absence of such tags, which can indicate vaginal agenesis. The presence of mucoid vaginal discharge is a normal finding. The discharge occurs due to an increase in estrogen during pregnancy followed by a drop after birth.
Which intervention should the nurse perform to determine the baseline measurements of a newborn's physical growth? 1 Place and hold the naked newborn on the scale to obtain weight. 2 Allow the caregiver to hold the infant while measuring its length. 3 Measure the circumference of the head just above the eyebrows. 4 Check for plantar reflex by placing a finger in the newborn's palm
3 The circumference of the newborn's head is measured at the widest part, which is the occipitofrontal diameter. The tape measure is placed around the head just above the infant's eyebrows. The nurse does not hold the infant while obtaining the weight; instead she places only a hand over the naked newborn to prevent it from falling off the scales. The nurse places the newborn on a flat surface with the head placed against a perpendicular surface with the legs extended until the knee is flat against the surface to measure length. The nurse checks for palmar reflex by placing a finger in the newborn's palm. The plantar reflex is checked by stimulating the base of the toes with a finger.
A postpartum patient is worried because her newborn's head has an abnormal shape instead of being round. The delivery documentation indicates that the newborn had molding upon delivery. What is nurse's best response? 1 "The infant will look better after more hair grows." 2 "The infant's skull needs to be massaged after a month." 3 "The infant's head will assume a normal shape in 3 days." 4 "Some infants have an oddly shaped head, which is alright."
3 The fetal skull bones are not completely fused and there may be a slight overlapping of the bones during the labor process. This causes molding of the fetal head. The molding is not permanent and the infant's head assumes a normal shape within 3 days of birth. Telling the patient that the infant will look better after hair growth will not help alleviate the patient's anxiety about the fetal head. The infant's head will assume a normal shape within 3 days, and the patient need not wait for a month to massage the infant's head. Some infants may have an oddly shaped head, but in this case, the molding has occurred due to the labo
Which feeding schedule should a nurse recommend to the mother of a newborn with true breast milk jaundice? 1 One to two feedings every 24 hours 2 Three to five feedings every 24 hours 3 Eight to 12 feedings every 24 hours 4 15 to 20 feedings every 24 hours
3 The recommended feeding schedule for a newborn with true breast milk jaundice is eight to 12 feedings every 24 hours. It is not sufficient to have one to two or three to four feedings every 24 hours. It is not necessary to have 15 to 20 feedings every 24 hours.
A nurse is working in the nursery and observes a nursing student repeatedly performing an Ortolani test. What priority action should the nurse take? 1 Assist the nursing student with performing the test to make sure that it is being done accurately. 2 Document the findings of the test as performed by the nursing student after the test has been repeated three times. 3 Have the nursing student explain what the test is used for in terms of clinical assessment. 4 Have the student stop performing the test immediately.
4 Although it would be important to ascertain if the nursing student knew the clinical implication for the test, the priority safety action would be to intervene and stop further testing. The Ortolani test should be performed by an experienced practitioner so as to avoid any possible damage. It should not be performed repetitively.
A mother of a newborn reports to the nurse that the child has bluish pigmentation on the back. What could be the reason for this condition? 1 Infection 2 Hypothermia 3 Polycythemia 4 Mongolian spots
4 Bluish pigmented areas on the back are a sign of Mongolian spots, which are not dangerous and usually fade in a few months. The bluish pigmentation is a common finding in the extrauterine life and does not indicate an infection. Polycythemia is the condition of accumulation of red blood cells on the face and gives a dark red-colored tint on the face, but not a bluish pigmentation on the skin. Hypothermia does not cause pigmentation of the body, though it may cause shivering in the newborn.
What is the principle source of bilirubin? 1 Bruising 2 Cephalhematoma 3 Production by adipocytes 4 Breakdown of red blood cells
4 The breakdown of red blood cells is the principle source of bilirubin. Bruising and cephalhematoma are sources of bilirubin but aren't principle sources. Bilirubin is not produced by adipocytes, but unconjugated bilirubin enters the subcutaneous fat and causes jaundice.
While caring for an infant, which method should the nurse adapt to prevent heat loss due to evaporation? 1 Wrap the infant in a cloth. 2 Place the infant in a warm crib. 3 Place the crib away from the windows. 4 Dry the infant immediately after the bath
4 The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.
The nurse finds that the neonate is not crying and has poor muscle tone at birth. What is the order of interventions that the nurse performs for this neonate? 1. Administering epinephrine if no response 2. Clearing the neonate's airway using suction 3. Giving oxygen therapy to the neonate 4. Performing chest compressions if no response
Poor muscle tone and the inability to cry at birth indicate that the neonate has respiratory depression, which can lead to hypoxia. The first step in resuscitation would be to clear the neonate's airway to facilitate breathing. The neonate has hypoxia, and therefore the neonate should be given oxygen therapy to restore the oxygen saturation levels. Chest compression is performed next to stimulate cardiac conduction. The last step of resuscitation includes administering epinephrine to the neonate to facilitate cardiac and pulmonary system activity.
The nurse is caring for a 2-hour-old newborn who has facial bruising as a result of a rapid delivery. The nurse obtains the following vital signs: temperature 98.2°F axillary, heart rate 142 beats/minute, and respirations 62 breaths/minute. Based on the nurse's assessment, which intervention takes priority? 1 Continuing to observe the newborn 2 Placing the newborn under the radiant warmer 3 Closing the infant's mouth and occluding one nostril at a time 4 Applying pressure to the infant's forehead with the index finger
The infant is tachypneic; therefore, the nursing intervention that takes priority is applying pressure to the infant's forehead with the index finger to assess for cyanosis. It is not appropriate to simply continue to monitor the infant. The infant's temperature is stable, so he or she does not need to be warmed. Closing the infant's mouth and occluding one nostril at a time is a test for choanal atresia.
