PrepU Query Quiz: Newborn
After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction? a) "Brain damage may occur if the molding does not resolve quickly." b) "The molding will usually disappear in a couple of days." c) "The amount of molding is related to the amount and length of pressure on the head." d) "The molding was caused by an overlapping of the baby's cranial bones during my labor."
"Brain damage may occur if the molding does not resolve quickly." Caput succedaneum is common after the use of a vacuum extractor to assist the client's expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding.
The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching? a) "Vitamin K will prevent my baby from developing an infection." b) "Vitamin K will help my baby breathe easier." c) "Vitamin K will prevent my baby from becoming jaundiced." d) "Vitamin K will help my baby's blood to clot properly."
"Vitamin K will help my baby's blood to clot properly." At birth, vitamin K-dependent blood clotting factors are significantly decreased, and there is a transitory deficiency in blood coagulation during the second and fifth days of life. As a preventive measure, 0.5 to 1 mg of vitamin K is administered to the newborn during the first day of life to aid in blood clotting. Vitamin K does not help improve respirations or make the baby breathe more easily; suctioning and oxygen are used as needed. Vitamin K does not prevent jaundice. If jaundice does appear, phototherapy is used. Vitamin K does not prevent infections; antibiotics are used if needed.
A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? a) Apply petroleum gauze to the site for 24 hours. b) Apply alcohol to the site. c) Keep the neonate in the supine position. d) Change the diaper as needed.
Apply petroleum gauze to the site for 24 hours. Petroleum gauze is applied to a circumcision site for the first 24 hours to prevent the skin edges from sticking to the diaper. Alcohol is contraindicated for circumcision care. Diapers are changed frequently, not as needed, to inspect the site. Neonates are initially kept in the prone position.
The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? a) Primarily, water supplements should be used to prevent jaundice. b) Formula feeding should be avoided to prevent interfering with the breast milk supply. c) Formula supplements can provide nutrients not found in breast milk. d) More vigorous sucking is needed for a bottle feeding, so supplements should be avoided.
Formula feeding should be avoided to prevent interfering with the breast milk supply. Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established. Bottle supplements are not appropriate to prevent jaundice, although if neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding. Breastfeeding is considered the best nutritional source for infants. Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.
The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean section 1 hour ago to a mother with insulin-dependent diabetes. She asks the nurse, "Why is my baby in the neonatal intensive care unit?" The nurse bases a response on the understanding that neonates of mothers with diabetes commonly develop which condition? a) anemia b) hypoglycemia c) hemolytic disease d) persistent pulmonary hypertension
Hypoglycemia Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class women with insulin dependent diabetes are about seven times more likely to suffer from respiratory distress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have polycythemia, not anemia. Anemia and hemolytic disease are associated with erythroblastosis fetalis. Persistent pulmonary hypertension is associated with meconium aspiration syndrome.
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis is the priority at this time? a) Hypothermia related to heat loss b) Risk for deficient fluid volume related to insensible fluid losses c) Risk for infection related to transition to the extrauterine environment d) Impaired parenting related to the addition of a new family member
Hypothermia related to heat loss The neonate's temperature should range from 97° to 97.7° F (36.1° to 36.5° C), and the respiratory rate should be less than 60 breaths/minute. (The respiratory rate increases as hypothermia develops.) Because this neonate's temperature is below normal and because cold stress can lead to respiratory distress and hypoglycemia, a diagnosis of Hypothermia related to heat loss takes highest priority. Impaired parenting related to the addition of a new family member, Risk for deficient fluid volume related to insensible fluid losses, and Risk for infection related to transition to the extrauterine environment may be appropriate, but don't take precedence over hypothermia, which can be life-threatening.
A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment? a) hyperbilirubinemia b) hypocalcemia c) low birth weight d) sedation
Low birth weight Neonates born to mothers who smoke tend to have lower-than-average birth weights. Neonates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death syndrome, bronchitis, allergies, delayed growth and development, and polycythemia. Maternal smoking is not related to higher neonatal sedation, hyperbilirubinemia, or hypocalcemia. Smoking may cause irritability, not sedation. Hyperbilirubinemia is associated with Rh or ABO incompatibility or the administration of intravenous oxytocin during labor. Approximately 50% of neonates born to mothers with insulin-dependent diabetes experience hypocalcemia during the first 3 days of life.
A nurse is performing a neurologic assessment on a neonate. Which sign is considered a normal finding in a neonate? a) Doll's eyes b) Positive Babinski's reflex c) Let-down reflex d) "Sunset" eyes
Positive Babinski's reflex A positive Babinski's reflex is present in neonates and infants until approximately age 1. However, this reflex is abnormal in adults. Doll's eyes are a neurologic response noted in adults. The appearance of "sunset" eyes, in which the sclera is visible above the iris, results from cranial nerve palsies and may indicate increased intracranial pressure. A neonate's pupils normally react to light in the same way as an adult's.
A neonate begins to gag and turns a dusky color. What should the nurse do first? a) Aspirate the neonate's nose and mouth with a bulb syringe. b) Notify the physician. c) Provide oxygen via a face mask as ordered. d) Calm the neonate.
Provide supplemental oxygen Recommended pulse oximetry reading in a full-term neonate is 95% to 100%. The saturation reading of only 75% is an indication that the neonate is not adequately oxygenating in room air. Providing supplemental oxygen will increase the neonate's oxygen saturation. Increasing the IV rate will not improve the oxygen saturation. Documenting the finding and taking no action is not appropriate with a saturation of 75%. Wrapping and increasing the body temperature of the neonate may increase the saturation reading only if it is inaccurate due to cold extremities. Caution must be used because overheating a neonate can be harmful.
While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. The nurse should explain to the parents that this will: a) require several surgeries to repair. b) be a normal symptom of a skull fracture that occurred during the birth. c) resolve without treatment by 6 weeks of age. d) remain swollen for at least 6 months before receding.
Resolve without treatment by 6 weeks of age. The neonate has a cephalohematoma, which usually resolves without treatment by 6 weeks of age. It is usually not present at birth and begins about 24 hours after birth. It is caused by pressure on the fetal skull during the birth process. Because of the breakdown of red blood cells within the hematoma, the neonate is at greater risk for hyperbilirubinemia. The neonate does not need repeated surgeries. The condition will resolve in 6 weeks, not 6 months. About 10% to 25% of neonates may have a skull fracture, but the skull fracture is not the cause of the hematoma.
A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease? a) Weight loss of less than 10% b) Frequent feeding patterns c) Signs of kernicterus d) Increased activity
Signs of kernicterus Neonates with an Rh and ABO incompatibility are likely to develop severe jaundice as a result of rising bilirubin. If bilirubin levels are high enough to cross the blood-brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment caused by permanent cell damage (kernicterus). Other findings in hemolytic disease include lethargy or irritability, poor feeding patterns, including vomiting, and possible weight loss of greater than 10%.
A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply. a) The neonate's toes do not fan out when soles of the feet are stroked. b) The neonate displays weak, ineffective sucking. c) The neonate doesn't respond when the nurse claps her hands above him. d) The neonate turns toward the nurse's finger when she touches his cheek. e) The neonate grasps the nurse's finger when she puts it in the palm of his hand. f) The neonate does stepping movements when held upright with sole of foot touching a surface.
• The neonate displays weak, ineffective sucking. • The neonate doesn't respond when the nurse claps her hands above him. • The neonate's toes do not fan out when soles of the feet are stroked. Perinatal asphyxia is an insult to the fetus or newborn due to the lack of oxygen. If the neonate's toes do not curl downward when the soles of the feet are touched and the neonate does not respond to a loud sound, neurologic damage from asphyxia may have occurred. A normal neurologic response would be the downward curling of the toes when touched and extension of the arms and legs in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate would grasp a person's finger when it is placed in the palm of the neonate's hand, do stepping movements when held upright with the sole of the foot touching a surface, and turn toward the nurse's finger when touching the cheek.
A teen client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression? a) "Sleep shouldn't be too much of a problem, because the baby will soon start to sleep through the night." b) "If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." c) "I am going to give the baby the best care possible without asking anyone for help to show all those people who think I cannot do it." d) "Since I'm breastfeeding, I can eat all the food I want and not feel fat. The baby will use all the calories."
"If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." Feelings of guilt combined with a lack of self-care (not eating or sleeping enough) can predispose a new mother to postpartum depression, especially one who has had previous episodes of depression. Sleep is essential to both the mother and baby, but sleeping through the night does not usually occur in the first few weeks after birth. While breastfeeding mothers do need good nutrition, eating as much as you want after childbirth may inhibit the return to a normal weight and could create depression in a new mother, especially a vulnerable one. Attempting to care for an infant with no help from others is likely to cause stress that could lead to depression, especially in an adolescent.
A client returns to the postnatal ward with her 3-week-old infant. Which statement by the client would prompt the nurse to document "Imbalanced nutrition less than body requirements related to inadequate intake"? a) The baby does not exhibit a steady weight gain." b) "The baby does not burp after a feeding." c) "The baby shows a desire to be fed every 3 to 4 hours." d) "The baby wets 10 to 12 diapers in 24 hours."
"The baby does not exhibit a steady weight gain." Signs that a neonate is not getting adequate intake include lack of weight gain, wetting 10 to 12 diapers in 24 hours, and showing contentedness after a feeding. ((Conflicting?)) Wetting 6 to 8 diapers in 24 hours signifies inadequate intake. Wanting to be fed every 1 to 2 hours indicates that the neonate isn't satiated. Burping after a feeding isn't associated with feeding adequacy.
According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate? a) "The vernix should be a thicker coating for a newborn." b) "The vernix is difficult and painful to remove from a newborn." c) "The vernix indicates a different gestational age than expected." d) "The presence of vernix affects the newborn's immune system."
"The vernix indicates a different gestational age than expected." Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.
A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which response by the nurse would be most appropriate? a) "You are Rh-negative and the baby is Rh-positive." b) "The baby and you are both Rh-positive." c) "You are Rh-positive, and the baby is Rh-negative." d) "You and the baby are both Rh-negative."
"You are Rh-negative and the baby is Rh-positive." Hemolytic disease of the newborn is associated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative the infant is Rh-positive. About 13% of Caucasians, 7% to 8% of people of African descent, and 1% of people of Asian descent are Rh-negative. Rh-positive cells enter the mother's Rh-negative bloodstream, and antibodies to the Rh-positive cells are produced. In a subsequent pregnancy, the antibodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia.
A neonate begins to gag and turns a dusky color. What should the nurse do first? a) Calm the neonate. b) Notify the physician. c) Aspirate the neonate's nose and mouth with a bulb syringe. d) Provide oxygen via a face mask as ordered.
Aspirate the neonate's nose and mouth with a bulb syringe. The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective.
A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? a) Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. b) Assign an Apgar score of 10, place in the neonate in modified Trendelenburg's position, and suction the neonate's nose. c) Assign an Apgar score of 6, place the neonate in modified Trendelenburg's position, and initiate a code to gain assistance from the code team. d) Assign an Apgar score of 7, place the neonate in modified Trendelenburg's position, and begin artificial respirations.
Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.
A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? a) Bathe the neonate only after his vital signs have stabilized. b) Wash the neonate from feet to head. c) Clean the neonate with medicated soap. d) Scrub the neonate's skin to remove the vernix caseosa.
Bathe the neonate only after his vital signs have stabilized. To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.
After a vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the health care provider (HCP) based on the analysis that this may be indicative of which anomalies? a) facial anomalies b) respiratory anomalies c) musculoskeletal anomalies d) cardiovascular anomalies
Cardiovascular anomalies Normally, the umbilical cord has two umbilical arteries and one vein. When a neonate is born with only one artery and one vein, the nurse should notify the HCP for further evaluation of cardiac anomalies. Other common congenital problems associated with a missing artery include renal anomalies, central nervous system lesions, tracheoesophageal fistulas, trisomy 13, and trisomy 18. Respiratory anomalies are associated with dyspnea and respiratory distress; musculoskeletal anomalies include fractures or dislocated hip; and facial anomalies are associated with fetal alcohol syndrome or Down syndrome, not a missing umbilical artery.
On examination of an African newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which of the following actions of the nurse is appropriate? a) Put a dressing over the pigmented area. b) Inform the physician about the condition. c) Ask the mother about any complications in pregnancy. d) Consider the finding as normal in Africans.
Consider the finding as normal in Africans. The nurse should consider the pigmented area as normal in Africans. These are called Mongolian spots, which are clusters of melanocytes. Asking the mother about complications in pregnancy, informing the physician about the condition, and putting a dressing over the pigmented area are inappropriate responses, because Mongolian spots are normal in Africans.
The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt and are exhibiting anxiety about how the neonate will be treated. Which action by the nurse would be most appropriate initially? a) Suggest that they make an appointment to talk things over with a counselor. b) Discuss the problem with the parents and the current feelings that they are experiencing. c) Ask them to share these concerns with the health care provider (HCP). d) Arrange a meeting with other parents whose infants have had successful clubfoot treatment.
Discuss the problem with the parents and the current feelings that they are experiencing. When an infant is born with an unexpected anomaly, parents are faced with questions, uncertainties, and possible disappointments. They may feel inadequate, helpless, and anxious. The nurse can help the parents initially by assessing their concerns and providing appropriate information to help them clarify or resolve the immediate problems. Referring the parents to the health care provider (HCP) is not necessary at this time. The nurse can assist the parents by listening to their concerns. Having them talk with other parents would be helpful a little bit later, once the nurse assesses their concerns and discusses the problem and the parents' current feelings. If the parents continue to have difficulties expressing and working through their feelings, referral to a counselor would be appropriate.
A nursery nurse just received the shift report. Which neonate should the nurse assess first? a) Four-hour-old term neonate with jaundice b) Twelve-hour-old term neonate who is small for gestational age c) Two-day-old term neonate in an open bassinette d) Six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation
Four-hour-old term neonate with jaundice The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? a) Breastfeeding is not recommended, because the neonate needs increased fat in the diet. b) Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. c) Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. d) Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.
Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.
A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. What would be the priority problem for this neonate? a) hyperglycemia b) risk for impaired patent-infant-child attachment c) impaired skin integrity d) impaired gas exchange
Impaired gas exchange The priority problem for the neonate with probable MAS is impaired gas exchange related to the effects of respiratory distress. Obstruction of the airways may be complete or partial. Meconium aspiration may lead to pneumonia or pneumothorax. Establishing adequate respirations is the primary goal. Impaired skin integrity is a concern, but establishing and maintaining an airway and gas exchange is always the priority. Hypoglycemia tends to be a problem for large-for-gestational-age babies, not hyperglycemia. If the parents do not express interest or concern for the neonate, then risk for impaired parent-infant-child attachment may be appropriate once the airway is established.
After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? a) Surgical intervention may be necessary to alleviate pressure. b) It is unusual when the brow is the presenting part. c) It is typically seen with breech births. d) It usually lasts a day or two before resolving.
It usually lasts a day or two before resolving. Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.
A neonate was admitted to the pediatric unit with an unexpected congenital defect. What is the best way to involve the parents in the neonate's care? a) Don't show the parents how to care for the neonate at this time. b) Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. c) Assume the parents have already been told how to care for their neonate. d) Tell the parents that they'll be shown one time how to do everything for the neonate before they take him home.
Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition. Many new parents need to grieve over the loss of a "normal" child. Therefore, adequate time and support should be given for the parents to adjust to the unexpected condition of their child. Never assume that the parents have already been educated about the neonate's care, or that they'll be able to learn everything they need to know after receiving instructions only once. The parents should be involved in the neonate's care during hospitalization because this involvement will help them learn and will instill confidence.
A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy? a) Small size for gestational age b) Postterm birth c) Large size for gestational age d) Appropriate size for gestational age
Small size for gestational age Neonates of women who smoked during pregnancy are small for gestational age for two reasons: Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus, and smokers are at greater risk for poor nutrition. These neonates are more likely to be preterm than postterm because smoking causes maternal vasoconstriction, decreases placental perfusion, and induces uterine contractions. Large size for gestational age results from increased nutrient transfer to the fetus such as in a neonate who receives excessive glucose from a mother with diabetes mellitus.
When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of: a) suffocation. b) gastroesophageal reflux (GER) c) sudden infant death syndrome (SIDS) d) aspiration.
Sudden infant death syndrome (SIDS) The supine position is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with supine positioning. ((Contradicts prior sentence?)) Although suffocation is less likely if the neonate is supine, the primary intervention for reducing suffocation risk is removing blankets and pillows from the crib. The position for GER requires the head of the bed to be elevated.
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)? a) temperature instability b) alkalosis c) positive Babinski's reflex d) increased muscle tone
Temperature instability The neonate is at high risk for sepsis due to exposure to the mother's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vomiting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respiratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski reflex is a normal finding and does not need to be reported.
