The Neonate

Which intervention takes priority when caring for a neonate immediately after birth? 1. Obtaining a Dextrostix result 2. Giving the initial bath 3. Administering a vitamin K injection 4. Covering the neonate's head with a cap

4. Covering the neonate's head with a cap RATIONALES: Covering the neonate's head with a cap helps prevent cold stress caused by excessive evaporative heat loss from the neonate's wet head. Initial baths aren't given until the neonate's temperature stabilizes. Dextrostix tests, which are performed on neonates at risk for hypoglycemia, are performed 30 minutes to 1 hour after birth. Vitamin K can be administered within 4 hours after birth.

While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following? 1. This is a normal adverse effect of phototherapy. 2. The baby is developing lactose intolerance and needs a soy-based formula. 3. The bilirubin is rising to dangerous levels. 4. The neonate may have a malabsorption problem.

1. This is a normal adverse effect of phototherapy. RATIONALES: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin levels are rising to dangerous levels.

As part of the respiratory assessment, the nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because: 1. neonates are obligate nose breathers. 2. nasal patency is required for adequate feeding. 3. problems with nasal patency may cause flaring. 4. a deviated septum will interfere with breathing.

1. neonates are obligate nose breathers. RATIONALES: Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for feeding a neonate. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties.

The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use? 1. 25G, 1" needle 2. 25G, 5/8" needle 3. 22G, 1" needle 4. 22G, 5/8" needle

2. 25G, 5/8" needle RATIONALES: Routinely, the nurse uses a 25G, 5/8" needle to administer prophylactic vitamin K to a neonate because this needle allows the medication to reach the muscle without causing excessive pain or trauma. A 1" needle is appropriate for an adult, not a neonate. The nurse uses a 22G needle only when administering thick medications such as penicillin.

The nurse is collecting data on a baby boy born 3 hours ago. Which finding would make the nurse suspect a congenital hip dislocation? 1. Limited abduction of the affected leg 2. Unequal gluteal folds 3. Lengthening of the limb on the affected side 4. Crepitus of the affected hip on movement

2. Unequal gluteal folds RATIONALES: Unequal gluteal folds are a sign of congenital hip dislocation. Other signs include unequal thighs, limited adduction — not abduction — of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted.

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? 1. Risk for aspiration related to prematurity 2. Deficient knowledge related to ventilatory support 3. Deficient knowledge related to apneic episodes 4. Deficient knowledge related to prematurity

3. Deficient knowledge related to apnea episodes RATIONALES: For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to apneic episodes is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after delivery but would probably be resolved by the time the neonate is ready for discharge.