Ob exam 3
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?1.Lethargy 2.Sleepiness 3.Constant crying 4.Cuddles when being held
A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.
The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo c. Smooth, pink skin with visible veins d. Faint red marks on the soles of the feet
A(Term infants typically have a flexed posture. Abundant lanugo usually is seen on preterm infants. Smooth, pink skin with visible veins is seen on preterm infants. Faint red marks usually are seen on preterm infants.)
Which of the following are reflex responses present at birth? A. Moro reflex B. Palmar flexion C. Fencer position D. Sucking and rooting E. Excessive yawning
A, C, D.
How would the newborn lose heat through convection?
Any procedure conducted uncovered has the potential side effect of baby losing heat through convection, nurse should be aware of any currents or fans in the room, and accommodate the newborn by ensuring there is a radiant heat source. Ambient Room Temp should stay 72-78 F.
What are some behavioral responses to pain in a newborn? A. Cooing B. Furrowed brows C. Chin quivering D. Closed mouth E. Flaccidity
B, C, E A- Not a pain cue D- Mouth with be open, and square shaped.
Infants of mothers with diabetes (IDMs) are at higher risk for developing: a. Anemia. b. Hyponatremia. c. Respiratory distress syndrome. d. Sepsis.
C (IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.)
What four mechanisms can heat loss occur by?
Conduction, Convection, Evaporation, and Radiation
How can the nurse be instrumental in preventing hypoglycemia in the newborn? Choose the best answer. a) Assessing the newborn's blood pressure within 1 hour of delivery b) Encouraging skin to skin for the first few minutes after birth c) Administering vitamin K within 1 hour of birth d) Encouraging early and frequent feedings
Encouraging early and frequent feedings CorrectExplanation: The best way listed above to prevent hypoglycemia in the newborn is encouraging early and frequent feedings with the breast or a bottle. Skin to skin will aid in keeping the newborn warm and preventing hypothermia, which in time will also help to prevent hypoglycemia. However, a few minutes is not enough to prevent low glucose levels. It would need to be done as often as possible. Vitamin K is given to prevent hemorrhage. Blood pressure is not routinely checked in healthy, term newborns.
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? a) Radiating b) Conductive c) Convective d) Evaporative
Evaporative Correct Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.
Ophthalmia neonatorum is caused by ________ or __________and can cause ___________?
Gonorrhea or chlamydia; blindness
Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Administered to give the infant better eye sight. b) Is a routine vitamin needed by the infant. c) Helps in formation of clotting factors, to prevent bleeding. d) Used to help infant fight infections.
Helps in formation of clotting factors, to prevent bleeding. CorrectExplanation: Vitamin K is necessary in the formation of certain clotting factors. The newborn is lacking in vitamin K and the only method for the infant to receive it is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut so the infant cannot manufacture vitamin K. Vitamin K is not administered to give the infant better eye sight nor is it to help fight infections.
A 32 weeker enters the emergency department c/o severe pain in her pelvic region and soon after delivers a baby boy. Upon immediate inspection the newborn is noted to be yellow in color, labs are drawn and the bilirubin is noted to be above 15mg/dL. Is this pathologic or physiologic jaundice?
Pathologic jaundice. Which usually is seen within the first 24hrs of life; It is caused by hemolysis or mother/baby blood incompatibility, sepsis, trauma, or liver disease. Can lead to neurotoxicity.
The nurse administers erythromycin ointment in the newborn's eyes and the mother asks why. The nurse should respond with:
Prevents ophthalmia neonatorum from occuring after delivery to a neonate born to a woman with an untreated gonococcal infection
How do you elicit the babinski reflex?
Stroking outer edge of sole of the foot, moving towards the toes. Toes will fan upward and out.
An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypocalcemia. c. Hypoglycemia d. Seizures.
(Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.)
How long after birth does the cord stump stay clamped?
24-48 hrs
What is the normal RR for a newborn?
30-60 breaths/min with short periods of apnea (less than 15 seconds)
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? 1. It usually resolves in 3-6 weeks 2. It doesn't cross the cranial suture line 3. It's a collection of blood between the skull and the periosteum 4. It involves swelling of tissue over the presenting part of the presenting head
4. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days. The edema in caput succedaneum crosses the suture lines. It may involve wide areas of the head or it may just be a size of a large egg. A collection of blood between the periosteum of a skull bone and the bone itself is a Cephalhematoma
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? 1. Candida albicans 2. Chlamydia trachomatis 3. Escherichia coli 4. Group B beta-hemolytic streptococci
4. transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 3 b) 4 c) 6 d) 5
5 CorrectExplanation:The infant is not demonstrating a good transition to extra uterine life; the APGAR score ranges from 0 to 10 with a score of 0, 1, or 2 points for each: respiratory effort, heart rate, tone, grimace, and color. A score of 5 indicates the infant need support. Options A, B, and D are incorrect Apgar scores based on the scenario provided.
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: a) 7 b) 6 c) 5 d) 8
7 CorrectExplanation: The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).
A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which of the following would be the total Apgar score for this newborn? a) 7 b) 6 c) 8 d) 9
8 Explanation:The heart rate of 110, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate: a. Meconium aspiration, hypoglycemia, and dry, cracked skin. b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome. c. Golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat. d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
A (Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.)
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."
A (Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.)
During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby."
A (Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their children. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman's husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.)
Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply): a. Polycythemia. b. Anemia. c. Congenital heart disease. d. Bronchopulmonary dysphasia. e. Retinopathy.
A, B, C(Risk factors for NEC include asphyxia, respiratory distress syndrome, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus, congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection.Bronchopulmonary dysphasia and retinopathy are not associated with NEC.)
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana
ANS: A The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.
A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (SATA) A. Chlorpromazine (Thorazine) B. Clonidine (Catapres) C. Diazepam (Valium) D. Phenobarbital (Luminal) E. Naloxone (Narcan)
ANS: A, B, C, D Several medications are used to treat the infants of drug-abusing mothers, including paregoric (camphorated tincture of opium), phenobarbital (Luminal), clonidine (Catapres), chlorpromazine (Thorazine), and diazepam (Valium). Naloxone (Narcan) is not used because it can increase the severity of drug withdrawal in the infant.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. Pharmacologic treatment. b. Reduction of environmental stimuli. c. Neonatal abstinence syndrome scoring. d. Adequate nutrition and maintenance of fluid and electrolyte balance.
ANS: C Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.
An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: a. Only if the newborn is in obvious distress. b. Once by the obstetrician, just after the birth. c. At least twice, 1 minute and 5 minutes after birth. d. Every 15 minutes during the newborn's first hour after birth.
C(Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts.)
Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. Early enteral feedings b. Breastfeeding c. Exchange transfusion d. Prophylactic probiotics
B (A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn's disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.)
The most common cause of pathologic hyperbilirubinemia is: a. Hepatic disease. b. Hemolytic disorders in the newborn. c. Postmaturity. d. Congenital heart defect.
B (Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.
B (Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.)
Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C Pneumothorax D. Macrosomia
D. Macrosomia. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin. Big baby >8 lb, 13oz (>4,000g)
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. Hypoglycemia. b. Phrenic nerve injury. c. Respiratory distress syndrome. d. Sepsis.
D (The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.)
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
D (This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.)
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.
D (This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.)
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborns mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls.
D. Epstein's pearls are small yellow-white nodules that appear of the roof of the newborns mouth,
A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Acrocyanosis. b) Erythema toxicum. c) Mumps. d) Yeast infection.
Erythema toxicum. CorrectExplanation: Erythema toxicum is a rash of unknown cause, with pink papules and superimposed vesicles. It appears within 24 to 48 hours after birth and resolves spontaneously in a few days. Acrocyanosis is a blue color of the hands and feet appearing in most infants at birth. Acrocyanosis may persist for 7 to 10 days. Yeast is a fungal infection caused by Candida albicans; it usually manifests in the groin. The rash of C. albicans is excoriated and does not disappear without treatment. The presentation described in this scenario is not consistent with that of mumps.
Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma b) Nevus flammeus c) Strawberry hemangioma d) Mongolian spot
Explanation: Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs of newborns. They tend to occur most often in children of Asian, Southern European, or African ethnicity and disappear by school age without treatment. Be sure to inform parents that although these marks look like bruises, they are not. Otherwise, they may worry their baby sustained a birth injury from improper handling. A nevus flammeus is a macular purple or dark-red lesion (sometimes called a port-wine stain because its color is the same as that of red wine). These lesions are present at birth and typically appear either on the face or a thigh. Strawberry hemangiomas are elevated areas formed by a combination of immature capillaries and endothelial cells. Cavernous hemangiomas are raised and irregular in shape ans so resemble a strawberry hemangioma in appearance but do not disappear with time.
It is important to NOT give the ________ and the _________ injections in the same thigh!
Hep B and Vitamin K
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother?1.Feed the newborn less frequently. 2.Continue to breast-feed every 2 to 4 hours. 3.Switch to bottle-feeding the infant for 2 weeks. 4.Stop breast-feeding and switch to bottle-feeding permanently.
Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.
What are three mechanisms that promote airway clearance in a newborn?
Infants cough reflex Mechanical suctioning Use of bulb syringe
A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops b) Instill antibiotic 0.5 percent erythromycin c) Instill 0.5 percent silver nitrate eye drops d) Wait to see if the eyes show signs of irritation before any eye care treatment is completed
Instill antibiotic 0.5 percent erythromycin CorrectExplanation: The standard eye care to prevent ophthalmia neonatorum is 0.5 percent erythromycin or 1 percent tetracycline eye drops. Although 1% silver nitrate drops where once used, it has not been shown to prevent chlamydial eye disease. One percent erythromycin and 0.5 percent silver nitrate are incorrect concentrations of these medications and should not be instilled into the eyes of the newborn. The nurse would not wait to see if the eyes show signs of irritation before completing eye care treatment on the newborn.
What are the torch infections and how do they affect babies?
T-Toxiplasmosis (from cat litter or raw meat) O-other (hep b, HIV, parvovirus, syphilis) R- Rubella( vaccine contraindicated in pregnancy) C- Cytomegalovirus H- Herpes TORCH infections can lead to sepsis.
When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Take blood, using a heel stick, to check for hypoglycemia. b) Place the child beneath a radiant warmer. c) Assess the baby's temperature with a thermal skin probe. d) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors.
Take blood, using a heel stick, to check for hypoglycemia. CorrectExplanation: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteryness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level with a heel stick. The infant described in the scenario does not need to be placed under a radiant warmer or have its temperature assessed with a thermal skin probe. You do not rule out hypoglycemia in an infant by checking the mother's chart to see if she is diabetic or has other risk factors.
The student nurse is caring for newborn that was just delivered and is clearing the airway for proper oxygenation. The nurse observes the infant coughing but notices the baby still having some issues breathing; the next step is using the bulb syringe and the nurse suctions both nostrils and then to the sides of the mouth. What did the nurse do wrong?
The nurse is suppose to suction to the side of the mouth, not down and the center and then one nostril at a time.
When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins b) Two arteries and two veins c) One artery and two veins d) Two arteries and one vein
Two arteries and one veinCorrectExplanation:The normal umbilical cord contains three vessels: two arteries and one vein.
A nurse is caring for a newborn in the nursery following a vaginal birth, the nurse notes, small raised pearly or white spots on the nose, chin and forehead. What could this be? Is it normal?
Yes it is normal, and it appears to be Milia which disappear spontaneously without treatment, should advise parents to not squeeze at these areas.
