Test 5: Newborn

A newborn has been diagnosed recently with transient tachypnea of the newborn. How should the nurse counsel the parents?

"I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run."

When thick meconium is present in a term infant, this does not produce a spontaneous cry. Place the following steps in the order in which they should occur.

* Call a health care provider skilled in intubation to the delivery room * Deliver the newborn * Intubate the newborn * Suction the airway below the vocal cords * Perform gastric lavage

A 1-minute-old newborn has a heart rate of 105 bpm, a pink body and blue feet, and a strong cry, along with sneezing and minimal flexion. What should the nurse assign as the 1-minute APGAR score?

8

FTI expected length is:

19 to 21 cm

The APGAR would be assigned as follows:

2 points for heart rate, 1 point for color, 2 points for respiratory effort, 2 points for reflexes, and 1 point for tone for a total of 8 points.

Full term infant expected weight:

2500 to 4000 g

A positive Babinski reflex can be seen until ?

3 months of age

FTI expected chest cirm.:

30.5cm to 33cm

FTI expected HC is:

33 to 35 cm

A newborn who is large for gestational age will weigh more than ______ grams.

4000

Physiologic jaundice occurs when?

48 hours or more after birth

When a fetus has chronic hypoxia in utero, what response does the nurse expect to see after birth?

Polycythemia

In which newborn should the nurse suspect hypoglycemia?

A jittery, irritable newborn with a high-pitched cry

The nurse would be concerned about hemolytic disease of the newborn in which case?

A woman who has anti-D antibodies and her newborn is A positive

Which newborn neuromuscular system adaptation would the nurse NOT expect to find?

An extrusion reflux at 9 months of age -- usually disappears around 4 months of age

You are the senior LVN/LPN in the newborn nursery and you are orienting a new graduate LVN/LPN. One of the subjects you want to cover today is hepatic adaptation of the normal newborn. What would you know to talk about?

AquaMEPHYTON

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which action would be most appropriate?

Assess the newborn for signs of respiratory distress.

When counseling a woman who is exclusively breastfeeding and is 6 weeks postpartum about her contraceptive options, which methods should the nurse include in her education?

Barrier methods, spermicides, the copper IUD, the hormonal IUD, and progesterone-only methods

Place the items regarding changes in fetal circulation at birth in which they occur. All options must be used.

Birth occurs. Pulmonary vascular resistance decreases. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes.

The nurse is preparing to administer a tube feeding to a preterm infant. When checking for residual prior to the feeding, there is a residual of 3 mL. What action should the nurse take?

Call the physician. -- report immediately gradually increasing residual and abdominal girth or return of more than 2 mL

A nurse is caring for a 3-hour-old newborn boy. The nurse makes the initial assessment and finds the following: respiratory rate 30 bpm, BP 60/40 mm/Hg, heart rate 155 bpm, axillary temperature 98.2° F (36.8° C). The nurse assesses that the newborn is in a state of quiet alert. What should the nurse do?

Document the data.

Ways to reduce heat lose by evaporation:

Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation

You are going to help a new mother begin breastfeeding. Which of the following would be most appropriate?

Encouraging her to lie on her side and help the baby become wide awake by talking to him

A nurse is assessing a newborn. What gestational age assessment findings indicate that the newborn has reached term?

Flexible wrist with a small angle at a range of 15 degrees

The nurse is caring for a newborn with fetal alcohol syndrome. The nurse knows that the newborn will demonstrate

Hyperactivity.

All of the following are signs of infection in a preterm newborn EXCEPT

Hyperreflexia

Which statement is false regarding newborn behavioral patterns?

In the first few hours after birth newborns do not typically demonstrate a response to visual stimuli.

You are assessing a newborn girl, four hours old, weighing 9 lbs. 2 oz. While doing the initial assessment the RN mentioned that the mothers' history showed her to be morbidly obese. You would know to observe this infant frequently for signs/symptoms of hypoglycemia. What would be early signs of hypoglycemia in this newborn?

Jitteriness and irritability

Examples of how to reduce heat loss via radiation

Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures

Examples of preventing heal loss via convection:

Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes

Low birth weight? Very Low birth weight? Extremely low birth weight?

LBW <2500 g VLBW <1500g ELBW <1000g

Why does breathing require greater effort for the preterm newborn?

Lack of surfactant

What would the nurse suspect in a premature newborn who has difficulty feeding and maintaining a stable temperature and is vomiting bile?

Necrotizing enterocolitis

The nurse in the newborn nursery has used the Ballard scoring system to assess the newborn. This gestational assessment evaluation includes which of the following categories of maturity of the newborn?

Neuromuscular and physical

If the nurse suspects IVH in a preterm newborn, which of the following would the nurse be likely to find?

No signs or only subtle signs

Which of the following is NOT a way to determine physical maturity in a newborn using the Ballard scoring system?

Posture

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

There are several ways in which a newborn can lose heat. A nurse moves a newborn's crib away from a cold window. Which type of heat loss would this action prevent?

Radiation

The student nurse is performing a Ballard scale on a newborn. The instructor assesses that the student understands methods to check neuromuscular maturity when she gently pulls the newborn's arm in front of and across the top portion of the body until resistance is met and identifies this action as:

Scarf sign.

The nurse is caring for a newborn who is lethargic, apneic, and not eating well, and has an axillary temperature of 36.2º C. Which might the nurse have a concern about?

Sepsis

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

Which of the following is NOT true regarding preterm birth?

The use of tocolytics has reduced the overall number of preterm births.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

A client has just given birth to a term infant who is not crying and has decreased tone. Place the nursing actions in the order they should be carried out. All options must be used.

Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate.

The classification of a low birth weight (LBW) is

a newborn that weighs less than 2,500 grams (g).

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production.

A nurse in a normal newborn nursery receives a report on four infants. Baby A is reported as being 16 hours old, vital signs within normal limits (WNL), bilirubin 3.5 mg/dL rooming in with mother; baby B is 8 hours old, vital signs WNL, bilirubin 3 mg/dL, returning to nursery for night; baby C is 19 hours old, vital signs WNL, bilirubin 4 mg/dL, rooming in with mother; baby D is 4 hours old, vital signs WNL, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first?

baby C Hyperbilirubinemia, (serum levels of four to six mg/dL and greater), can lead to jaundice.

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

A nurse is conducting a refresher in-service program for a group of neonatal nurses. After teaching the group about hepatic system adaptations after birth, the nurse determines that the teaching was successful when the group identifies which process as reflective of the change of bilirubin from a fat-soluble product to a water-soluble product?

conjugation

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn?

convection and evaporation

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

evaporation

At birth, changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close?

higher oxygen content of the circulating blood

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

intraventricular hemorrhage (IVH)

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth

Pathologic jaundice occurs when?

within the first 24 hours of life and is often related to blood incompatibility

What is the responsibility of the registered nurse (RN) after the delivery of the newborn? (Select all that apply.)

• Assessing the gestational age. • Identifying potential complications. • Initiating the plan of care

What clinical manifestations may indicate to the nurse that the preterm infant has developed an intraventricular hemorrhage (IVH)? (Select all that apply.)

• Cyanosis • Bradycardia • Bulging fontanelles • Hypotonia

For a formula-fed newborn, which of the following factors may lead to inadequate nutritional intake by the newborn? Select all that apply.

• Emesis after each feeding • Diarrhea • Gastroesophageal reflux • Refusal to eat

Which assessment findings made by the nurse indicate successful transition of the newborn to extra uterine life immediately following the birth? (Select all that apply.)

• Heart rate above 100 beats per minute • Vigorous cry

The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? (Select all that apply.)

• Hepatitis B immune globulin • Hepatitis B vaccination

The nurse is caring for a preterm infant in the newborn nursery. Which of the following would be appropriate nursing diagnosis for this infant? (Select all that apply)

• Ineffective breathing pattern • Ineffective thermoregulation • Risk for impaired skin integrity

Which of the following is true of APGAR scoring? Select all that apply.

• It is done at 1 and 5 minutes after birth. • The baby is considered vigorous if the 5-minute score is above 7. • The APGAR score is an immediate assessment of newborn cardiopulmonary adaptation.

The nurse knows to assess physical maturity as part of the Ballard scare. Which of the following would the nurse assess? (Select all that apply.)

• Lanugo • Eye-ear • Plantar surface

An infant is experiencing transient tachypnea of the newborn (TTN). Symptoms that may be seen in this infant include: (Select all that apply.)

• Nasal flaring. • Retractions. • Respirations of 60 per minute. • Expiratory grunting.

All of the following complications are more likely to develop in a large for gestational age (LGA) newborn as opposed to an appropriate for gestational age (AGA) newborn EXCEPT

Polycythemia

How can the nurse promote adequate ventilation and respiratory support in a preterm newborn? Select all that apply

• Reposition the newborn every 2 hours • Suction the airway • Elevate the head of the bed • Observe for changes in respiratory effort • Encourage organized rest times

Which of the following is a cause of retinopathy of prematurity (ROP)? Select all that apply.

• Oxygen saturation maintained above 95% • Presence of immature retinal blood vessels

Why is the preterm newborn at greater risk than a term newborn for intraventricular hemorrhage (IVH)? Select all that apply.

• Premature and very fragile capillary system surrounding the brain • Poor ability to autoregulate cerebral pressure • Overstimulation or brisk, abrupt movements

The nurse is orienting a student to the nursery. The nurse understands that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

• nasal flaring • respiratory rate greater than 60 breaths per minute • retractions • heart rate greater than 100 beats per minute

Why is good nutrition so crucial for newborns? (Select all that apply.)

• optimal growth • optimal development • psychological needs

The nurse is caring for a baby born to a mother with a history of alcohol abuse. For what characteristics should the nurse observe to determine if the newborn has fetal alcohol syndrome? Select all that apply.

• reduced ocular growth • short palpebral fissures • flattened nasal bridge

While teaching a student, the nurse should include which signs and symptoms to recognize hypoglycemia in the neonate? Select all that apply.

• tachypnea • jitteriness • poor feeding

After birth of the neonate, which interventions would promote parental attachment? Select all that apply

• touching • swaddling • skin-to-skin contact • breastfeeding