Test 2 Review - Ch 18
Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? When the infant is 48 hours old 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents Just before discharge home
Correct response: 24 hours after the newborn's first protein feeding Explanation: The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.
A newborn male has just returned to the mother's room after being circumcised. Which behaviors will concern the nurse? Appearing very sleepy Being restless and crying Having a bowel movement An apical pulse of 150
Correct response: Being restless and crying Explanation: If a newborn is in pain, he/she will be crying, restless, have facial grimacing, increased heart rate and increased blood pressure. Bowel movements and urination are expected. Newborns respond to pain and stress by sleeping. An apical pulse rate of 150 is normal for a newborn
What signs does a nurse observe for when assessing neurologic maturity to determine gestational age in a newborn?
The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.
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: 5. 6. 7. 8.
Correct response: 7. Explanation: 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 newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge
Correct response: After the newborn has completed the antibiotic therapy Explanation: It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.
Which newborn neuromuscular system adaptation would the nurse not expect to find? an extrusion reflex at 9 months of age a Moro reflex at 3 months of age a positive Babinski reflex at 2 months of age a plantar grasp reflex at 7 months of age
Correct response: an extrusion reflex at 9 months of age Explanation: An extrusion reflex usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.
Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications? weight = 2000 g, length = 17 inches (43 cm), head circumference = 32 cm, and chest circumference = 30 weight = 2500 g, length = 18 inches (46 cm), head circumference = 32 cm, and chest circumference = 30 cm weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm weight = 4500 g, length = 22 inches (56 cm), head circumference = 36 cm, and chest circumference = 34 cm
Correct response: weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm Explanation: For a term infant, expected weight is 2500 to 4000 g; length is 19 to 21 inches (48 to 53 cm); head circumference is 33 to 35 cm; and chest circumference is 30.5 to 33 cm.
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? Test the newborn for HIV Bathe the newborn thoroughly Administer zidovudine Assist the mother to breastfeed
Correct response: Bathe the newborn thoroughly Explanation: The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.
The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply. Chlamydia Gonorrhea Trichomonas Syphilis Candidiasis
Correct response: Chlamydia Gonorrhea Explanation: Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn, which infants contract as they are birthed. The treatment is the use of an antibiotic ophthalmic ointment which is applied usually within the first hour. Trichomonas, syphilis, and candidiasis do not cause ophthalmia neonatorum
The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply. Bradypnea Jitteriness Lethargy Seizures Hyperthermia
Correct response: Jitteriness Lethargy Seizures Explanation: Signs and symptoms of hypoglycemia in newborns can include jitteriness, lethargy, cyanosis, apnea, high-pitched or weak cry, hypothermia, and poor feeding. Respiratory distress, apnea, seizures, and coma are late signs of hypoglycemia. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur
When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used. Pink coloration is lost. Respiratory effort decreases. Muscle tone decreases. Reflex irritability is noted. Heart rate decreases.
Correct response: Pink coloration is lost. Respiratory effort decreases. Muscle tone decreases. Reflex irritability is noted. Heart rate decreases. Explanation: The Apgar score is a method of evaluating a newborn's physical condition at 1 and 5 minutes after birth. Assessment is an indication of the newborn's overall central nervous system status. When the newborn experiences physiologic depression, the characteristics disappear in a predictable manner: first the pink coloration is lost, next the respiratory effort, then the tone, followed by reflex irritability, and finally the heart rate
Assessment of a newborn reveals microcephaly. The nurse recognizes that this newborn may also have which complications? Select all that apply. epilepsy cerebral palsy hearing disorders hydrocephalus achondroplasia
Correct response: epilepsy cerebral palsy hearing disorders Explanation: Infants with microcephaly are also noted to have additional complications such as epilepsy, cerebral palsy, intellectual disability, and ophthalmologic and hearing disorders. Hydrocephalus and achondroplasia are more commonly seen with macrocephaly
A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply. lanugo genitals arm recoil scarf sign posture
Correct response: lanugo genitals Explanation: Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity