OB Chapt 23 Nursing Care of the Newborn With Special Needs(nclex questions – Flashcards
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When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation
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Conduction Correct Explanation: A conduction heat loss results from direct contact with an object that is cooler.
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A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a) The newborn was exposed to an infection while in utero. b) The newborn aspirated meconium, causing the wasted appearance. c) A postterm newborn has begun to break down red blood cells more quickly. d) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.
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With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.
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A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant
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Term, small for gestational age, and low-birth-weight infant Correct Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).
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A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Administration of oxygen via a bag and mask b) Intubation and suctioning of the trachea c) Gently shaking the infant d) Flicking the sole of the infant's foot
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Intubation and suctioning of the trachea Correct Explanation: Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. Do not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.
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Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46
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Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.
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The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The neonate has 7 to 10 mm of breast tissue. c) The skin is pale, and no vessels show through it. d) Creases appear on the interior two-thirds of the sole.
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The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.
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Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn
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• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.
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The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia
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Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.
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A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Meconium aspiration in utero or at birth b) Yellow appearance of the newborn's skin c) Tremors, irritability, and high-pitched cry d) Seizures, respiratory distress, cyanosis, and shrill cry
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Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.
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The mother of a preterm infant tells her nurse that she would like to visit her newborn, who is in the neonatal intensive care unit (NICU). Which of the following would be the most appropriate response by the nurse? a) "I'm sorry. You may not visit your son until he has been released from the NICU." b) "Certainly. You may only observe the child from a distance, however, as his immune system is still not developed adequately." c) "Certainly. You will need to wash your hands and gown before you can hold him, however." d) "I'm sorry. You may not visit the NICU, but we can arrange to have your son brought to your room so that you can hold him."
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"Certainly. You will need to wash your hands and gown before you can hold him, however." Correct Explanation: Be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.
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An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypoglycemia b) Hypertension c) Hypotension d) Hyperglycemia
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Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.
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A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis
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Peeling and wrinkling of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.
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After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate
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Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.
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A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Promotes clearing of mucus from the respiratory tract c) Assists with ciliary body maturation in the upper airways d) Helps maintain a rhythmic breathing pattern
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Helps the lungs remain expanded after the initiation of breathing Correct Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasn't been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.
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A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g
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Less than 1,500 g Correct Explanation: A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birthweight newborn typically weighs about 2,500 g. An extremely-low-birthweight newborn weighs less than 1,500 g.
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A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.
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• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper. Explanation: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.
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A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal
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Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.
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The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.
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• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
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The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying
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Apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.
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Which of the following data is indicative of hypothermia of the preterm infant?
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Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.
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A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus
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Respiratory distress syndrome Correct Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.
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Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g
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2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.
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Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 30 mg/100 mL whole blood b) 100 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 80 mg/100 mL whole blood
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40 mg/100 mL whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia
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Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Soft brown b) Sticky forest green c) Seedy yellow d) Formed green
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Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.
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Which of the following would you expect to assess in an infant with hypoglycemia? a) Prolonged jaundice b) Limpness or jitteriness c) Pain along the sixth cranial nerve d) Excessive hunger
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Limpness or jitteriness Correct Explanation: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.
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Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities
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Cluster care and activities Correct Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.
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Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings
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Sunken fontanels Correct Explanation: Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.
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A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.
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One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.
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The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant has hand in mouth b) Infant is kicking feet c) Infant is crying d) Infant is quiet
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Infant has hand in mouth Correct Explanation: Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.
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Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Sunken abdomen c) Narrow skull sutures d) Poor muscle tone over buttocks e) Increased subcutaneous fat stores
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• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.
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A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms
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Shiny heels and palms Correct Explanation: A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in post-term newborns and is excessive in premature infants.
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The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? a) Diabetes b) Celiac disease c) Alcohol use d) Hypertension
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Diabetes Correct Explanation: In the condition known as macrosomia, a newborn is born large for gestational age (LGA). These newborns are those with birth weights that exceed the 90th percentile of newborns of the same gestational age. They are born most often to mothers with diabetes.
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A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Increased amounts of vernix. b) Absence of lanugo. c) Meconium aspiration. d) Hypoglycemia.
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Increased amounts of vernix. Correct Explanation: 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 postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.
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Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True
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True
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A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) expiratory grunting. c) inspiratory stridor. d) expiratory wheezing.
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expiratory grunting. Correct Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).
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Infants of drug-dependent women tend to be large for gestational age. a) False b) True
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False Infants of drug-dependent women tend to be small for gestational age.
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A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.
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ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.
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A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Head larger than body b) Brown lanugo body hair c) Round flushed face d) Protuberant abdomen
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Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.
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A client's gestational age is 38 weeks and 6 days. If the baby is born today, which of the following terms accurately describes the gestational age of the newborn? a) Term. b) Premature. c) Postterm. d) Preterm.
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Term. Correct Explanation: A term infant is born after the beginning of week 38 and before week 42 of pregnancy. Premature or preterm refers to the birth prior to 37 completed weeks. Postterm refers to birth beyond 42 weeks.
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A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The infant may have excess of lanugo and vernix caseosa. c) The testes in the child may be undescended. d) The newborn may look wrinkled and old at birth.
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The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.
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A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Tip the infant into an upright position b) Immediately suction the infant's airway c) Take a blood sample d) Place the infant supine in a radiant heat warmer
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Tip the infant into an upright position Explanation: It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.
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If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.
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Feed the infant. Correct Explanation: The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.
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A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a) Late preterm b) Term c) Preterm d) Postterm
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Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation
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What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal
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Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.
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When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Fetal exposure to low estrogen levels b) Low weight gain during pregnancy c) Maternal pregravid obesity d) Low maternal birth weight
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Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.
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A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis
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Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.
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The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia
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Polycythemia probably due to chronic fetal hypoxia Correct Explanation: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores
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A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse
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Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.
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What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.
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Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.
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A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 20 c) 5 d) 9
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20 Explanation: AGA infants are infants that fall between the 10th and 90th percentile for weight.
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While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise
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A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.
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An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.
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Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.
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With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 180 mm Hg b) 50 mm Hg c) 100 mm Hg d) 40 mm Hg
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100 mm Hg Explanation: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.
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All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose mother craved chocolate during pregnancy b) An infant whose labor began with ruptured membranes c) An infant who has marked acrocyanosis of his hands and feet d) An infant who had difficulty establishing respirations at birth
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An infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.
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Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia
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Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.
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The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue
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• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue Explanation: Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.
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What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%
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10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.
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When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Serum glucose level of 60 mg/dl b) Jitteriness c) Hyperalert state d) Loud and forceful crying
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Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Weak crying is found in babies with hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.
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An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.
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RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).
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A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis
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Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.
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Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Decreased muscle mass b) Face is angular and pinched c) Decreased body temperature d) Ability to tolerate early oral feeding
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Ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature and an angular and pinched face are features common to both an SGA and a preterm baby.
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Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Seizures c) Feeble sucking d) Asymmetrical movement
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Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.
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A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Normal birth weight b) Very low birth weight c) Extremely low birth weight d) Low birth weight
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Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight
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The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction
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Radiation Correct Explanation: Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.
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A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.25 mL b) 0.20 mL c) 0.15 mL d) 0.1 mL
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0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.
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A nurse is caring for a large for gestational age newborn. Which of the following signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) Bulging fontanels b) Lethargy and stupor c) Appearance of central cyanosis d) Respiratory difficulty e) High-pitched shrill cry
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• Lethargy and stupor • Respiratory difficulty • Appearance of central cyanosis Explanation: The features indicating hypoglycemia in LGA infants include lethargy, stupor and fretfulness, respiratory difficulty and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak whimpering cry. High-pitched shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.
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A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification
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Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.
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When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.
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Place the newborn's head in a neutral position. Correct Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.
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A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.
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Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.
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In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity
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Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.
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A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The newborn may look wrinkled and old at birth. c) The testes in the child may be undescended. d) The infant may have excess of lanugo and vernix caseosa.
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The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants
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A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag
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Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.
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A newborn that has a surfactant deficiency will have which assessment noted on a physical exam: a) Pink skin b) Regular respirations c) Hypertension d) Grunting
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Grunting Correct Explanation: Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.
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The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation? a) "That means your baby is over the 90th percentile for weight." b) "That means your baby is in the 5th percentile for weight." c) "That means that your baby is lazy sometimes." d) "That means your baby is average for gestational age."
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"That means your baby is over the 90th percentile for weight." Correct Explanation: LGA stands for large for gestational age. These infants are over the 90th percentile for weight. The other choices are not over the 90th percentile for weight or describe a different characteristic.
