OB R&R ch 13 (the complicated newborn experience) – Flashcards
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The nurse is admitting a neonate two hours after delivery. Which assessment data should the nurse be concerned about? Select all that apply. 1. Hands and feet blue with otherwise pink color 2. Bilateral nasal flaring 3. Minimal response to verbal stimulation 4. Apical heart rate 140-156 5. Chest retractions
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Answer: 2, 5 Rationale: Nasal flaring and chest retractions could be signs of respiratory distress and require immediate intervention. Blue hands and feet, a minimal response to verbal stimulation and apical heart rate of 140-156 are normal findings for a neonate at two hours of age. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Critical words are neonate two hours after delivery and be concerned about. This indicates the need to look for abnormal signs that indicate a problem. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 608.
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Of the following nursing diagnoses for a high-risk newborn, which requires the most immediate intervention by the nurse? 1. Acute Pain related to frequent heel sticks 2. Imbalanced Nutrition: Less Than Body Requirements related to limited oral intake 3. Ineffective Airway Clearance related to pulmonary secretions 4. Deficient Knowledge related to infant care needs
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Answer: 3 Rationale: Maintaining a patent airway is the highest priority when providing care for a newborn. A newborn's condition will deteriorate rapidly without a patent airway. Pain is an important safety need, but airway, breathing, and circulation take priority. Nutrition is important to maintain life but is not the highest priority diagnosis for the high-risk newborn. Deficient Knowledge relates to the parents and has the lowest priority because it is psychosocial in nature. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Remember ABCs. Maintaining an open airway would be the priority. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 608-609.
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On admission to the nursery it is noted that the mother's membranes were ruptured for 48 hours before delivery and her temperature is 102°F (38.9°C). What information from this newborn's assessment should the nurse evaluate further? 1. Temperature instability 2. Irregular respiratory rate 3. Jitteriness 4. Excessive bruising of presenting part
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Answer: 1 Rationale: This newborn is at risk for sepsis caused by prolonged rupture of membranes and maternal fever. A primary sign of sepsis in the newborn is temperature instability, particularly hypothermia. An irregular respiratory pattern is normal. Jitteriness may be a sign of hypoglycemia. Excessive bruising is often related to a difficult delivery with an increased risk of hyperbilirubinemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is the risk for neonatal sepsis. The correct answer would be the option that contains abnormal assessment data related to infection in the newborn. Eliminate incorrect options because they are not related to sepsis. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 482, 783-787.
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The nurse would take which action as part of nursing care of the infant experiencing neonatal abstinence syndrome? 1. Place stuffed animals and mobiles in the crib to provide visual stimulation. 2. Position the baby's crib in a quiet corner of the nursery. 3. Avoid the use of pacifiers. 4. Spend extra time holding and rocking the baby.
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Answer: 2 Rationale: Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period. Pacifiers allow for nonnutritive sucking by the infant. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recall that neonatal abstinence syndrome is accompanied by hyperstimulation of the central nervous system. The correct answer would be the option that contains a strategy to reduce stimulation. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 724, 729, 731.
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A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care for the infant, what is an important goal of the nurse? 1. Prevent the development of ophthalmia neonatorum. 2. Lubricate the eyes. 3. Prevent the development of thrush. 4. Teach the danger of breastfeeding with gonorrhea.
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Answer: 1 Rationale: A newborn can become infected with gonorrhea as he or she passes through the birth canal. Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All babies' eyes are treated with an antibiotic prophylactically after birth. The eyes require antibiotic prophylaxis, not lubrication. Thrush would result from a yeast infection rather than gonorrhea. There is no risk for breastfeeding because of gonorrhea. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is providing safety for the newborn of a mother with a gonococcal infection. The correct answer would be the option that contains a true statement to prevent spread of infection from mother to infant. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 738-739.
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A full-term newborn weighed 10 pounds, 5 ounces at birth. What would be a priority nursing diagnosis for this infant? 1. Ineffective Thermoregulation related to lack of subcutaneous fat 2. Risk for Injury related to macrosomia 3. Impaired Gas Exchange related to lack of surfactant 4. Deficient Knowledge related to newborn care
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Answer: 2 Rationale: Newborns experiencing macrosomia are more likely to experience birth injuries during delivery. Nursing care after delivery should focus on assessing for signs of birth injuries and intervening if appropriate. The risks related to ineffective thermoregulation are the same as for other infants born at term. A mature newborn has sufficient surfactant for gas exchange. Teaching would be a priority for the parents, but is a psychosocial need and takes precedence once the infant's physiological needs are attended to. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The core issue of the question is an abnormally large infant. The correct answer would be the option that contains a true statement of a risk for this newborn. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 517-518.
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The nurse finds the mother of a 28 weeks' gestation infant crying in her room. The mother states, "I just know my baby is going to die." What is the most therapeutic response by the nurse? 1. "I know this seems overly optimistic, but it is likely that everything will be fine." 2. "Why do you think that?" 3. "You seem very worried about what will happen to your baby." 4. "My baby was born at 27 weeks and he is fine now."
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Answer: 3 Rationale: Reflecting on what the client said offers the client an opportunity to share feelings. It is important to avoid giving false reassurance. It is important to avoid asking clients "why" they feel the way they do. Talking about personal experiences is nontherapeutic and does not address the client's concerns. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 721.
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A nurse is admitting an infant of a diabetic mother (IDM). At 1 hour of age, the nurse notices that the newborn is very jittery. Which action by the nurse is most appropriate? 1. Begin oxygen by nasal cannula. 2. Assess the newborn's blood glucose. 3. Place the newborn under a radiant warmer. 4. Initiate use of a cardiac/apnea monitor.
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Answer: 2 Rationale: Infants of diabetic mothers are at risk for hypoglycemia after delivery. A primary sign of hypoglycemia is jitteriness. The newborn is not showing any signs of hypoxia so oxygen would not be appropriate. Putting the newborn under a warmer or on a monitor would not harm the infant, but they are not the priority interventions at this time. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Knowledge of the care of the newborn of a diabetic mother will aid in answering the question correctly. Recall that blood glucose is the primary test to assess diabetic control. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 704-707.
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A newborn's temperature is 97.4°F. What is the priority nursing intervention by the nurse? 1. Notify the health care provider immediately. 2. Take the newborn to the nursery and observe for two hours. 3. Reassess the temperature in four hours. 4. Wrap the newborn in two warm blankets and place a cap on the head.
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Answer: 4 Rationale: This newborn has a low temperature and the nurse must intervene quickly to prevent complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation and is the most important initial intervention. It is unnecessary to notify the health care provider at this time. Observing the infant for two hours delays care and is unsafe. Reassessment of temperature does not do anything to raise the infant's temperature at this time. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal finding indicating cold stress. The correct answer would be the option that counteracts this problem and safely warms the newborn. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 637-638.
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A nurse is assessing a neonate born 12 hours ago and notes a yellow tint to the sclera. The nurse should read the medical record for what other assessment that is important to note at this time? 1. Blood glucose level 2. Blood type and Rh factor of both mother and newborn 3. Most recent infant blood pressure 4. Length of time membranes ruptured prior to delivery
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Answer: 2 Rationale: This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice is considered pathologic if it occurs within the first 24 hours of life, when it is most often caused by Rh or ABO incompatibility. It would be important to assess both the mother's and newborn's blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained. A blood glucose level would be important if the infant showed signs of hypoglycemia. The most recent infant blood pressure is not relevant. The length of time membranes ruptured prior to delivery would affect the risk of maternal infection. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: This question requires further assessment of jaundice, an abnormal finding in a newborn at this age. The correct answer would be the option that contains information related to pathologic jaundice. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 771.
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The parents of a 28 weeks' gestation neonate ask the nurse, "Why does he have to be fed through a tube in his mouth?" What is the nurse's best response? 1. "It allows us to accurately determine the baby's intake since he is so small." 2. "The baby's sucking, swallowing, and breathing are not coordinated yet." 3. "The baby's stomach cannot digest formula at this time." 4. "It helps to prevent thrush, an infection that could affect the baby's mouth."
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Answer: 2 Rationale: Neonates generally are not able to effectively coordinate sucking, swallowing, and breathing until 34-36 weeks' gestation. If fed orally before that time, they are at greater risk of aspiration. Typically they will be fed through a gavage tube until they are able to drink from a bottle or breastfeed. Intake can be accurately assessed with oral and gavage feedings but this is not the primary reason. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage through the birth canal and gavage feedings will not prevent it from occurring. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that the correct option is also a true statement. Recall the preterm neonate's capabilities regarding nutritional intake to choose the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 714-715.
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Which nursing diagnosis should have highest priority for the nurse who is caring for a preterm newborn? 1. Ineffective Thermoregulation related to lack of subcutaneous fat 2. Grieving related to loss of "perfect delivery" 3. Imbalanced Nutrition: Less Than Body Requirements related to immature digestive system 4. Risk for Injury related to thin epidermis
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Answer: 1 Rationale: Newborns compensate for hypothermia by metabolizing brown fat. This process requires glucose and oxygen. Preterm newborns are at risk for hypoglycemia and respiratory distress, so hypoglycemia can further increase their needs for oxygen and glucose and cause serious complications. The other diagnoses are appropriate but not the highest priority. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Remember ABCs. The correct answer would be the option that contains a true statement that could negatively impact breathing and circulation. Cold stress can contribute to respiratory distress. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 709
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A nurse is caring for a 12-hour-old newborn. The nurse notes a yellow tint to the baby's skin and sclera. What laboratory tests should the nurse anticipate being ordered? Select all that apply. 1. Serum glucose 2. Direct Coombs' test 3. Blood culture and sensitivity 4. Hemoglobin 5. Total bilirubin
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Answer: 2, 4, 5 Rationale: Jaundice in an infant less than 24 hours of age is often caused by Rh or ABO incompatibility. A direct Coombs' test determines the presence of maternal antibodies in the baby's blood. Hemoglobin will provide additional crucial information about possible red blood cell destruction. Total bilirubin is a helpful test to determine the amount of circulating bilirubin that can lead to increased jaundice. A serum glucose test would be useful if the infant was showing signs of hypoglycemia. Blood culture and sensitivity would be useful for the infant suspected of being septic. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is jaundice. Eliminate incorrect options because they do not provide data related to this abnormal condition. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 772-773.
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A newborn is admitted with a diagnosis of transient tachypnea of the newborn (TTN). When planning nursing care for this baby, what nursing goal should the nurse formulate? 1. Promote adequate quantity of surfactant. 2. Promote absorption of fetal lung fluid. 3. Assist in removal of meconium from airway. 4. Stimulate respirations.
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Answer: 2 Rationale: Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. Nursing care is focused on supporting oxygenation needs to allow the newborn's body to reabsorb the fluid. Inadequate surfactant is related to prematurity and respiratory distress syndrome. Meconium in the airway results in meconium aspiration syndrome and is usually associated with fetal asphyxia. TTN causes tachypnea so stimulating respirations is not appropriate. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Recall that transient tachypnea is associated with amniotic fluid in the newborn lungs. Eliminate incorrect options because they are not related to this problem. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 759-760.
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The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse? 1. Loose, green stools 2. Yellow tint to skin 3. Temperature 97.2°F 4. Fine, red rash on trunk
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Answer: 3 Rationale: Infants should be unclothed while receiving phototherapy to increase the circulating blood volume exposed to the phototherapy light. However, this increases the risk of temperature instability and infant temperature should be monitored carefully. Any temperature below 97.6°F is considered hypothermia and requires immediate attention. Loose, green stools and a yellow tint to the skin are expected findings with hyper-bilirubinemia. A fine, raised red rash may appear on the infant's skin as a side effect of the phototherapy and does not require intervention. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal finding in the present treatment of jaundice. Eliminate incorrect options because they are normal findings in a newborn with jaundice being treated with phototherapy. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 773-777.
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A mother is crying while sitting by the isolette of her premature newborn who was born at 25 weeks' gestation. What is the most therapeutic communication by the nurse? 1. "It's important to try not to worry. Let's hope that everything will work out." 2. "Can you tell me some specific things that have gotten you upset?" 3. "Would you like me to call the hospital chaplain? This has helped many others." 4. "This must be hard for you. Can you share with me what has you most concerned at this time?"
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Answer: 4 Rationale: Reflection allows the client to verbalize his or her feelings. The nurse should not give the client false hope. Clients often do not know why they feel the way they do and it is not helpful to ask them to determine this. Some clients may find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings and invites further communication by the client. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 791-794.
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A baby's mother is HIV-positive. Which intervention is most important for the nurse to include when planning care for this newborn? 1. Encourage the mother to breastfeed. 2. Administer zidovudine (ZDV) after delivery. 3. Cuddle the baby as much as possible. 4. Place the baby's crib in a quiet corner of the nursery.
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Answer: 2 Rationale: Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapar-tally, as well as to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by 60-70%. Breastfeeding is contraindicated in an HIV-positive mother because the virus can be passed through breast milk. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The core focus of the question is reduction of HIV transmission from mother to infant. The correct option contains a true statement to reduce the risk of transmission of the disease to the newborn. Eliminate options that are either unrelated to HIV transmission or that would increase risk of transmission. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 669, 737-738.
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The nurse is preparing to initiate bottle-feeding in a preterm infant. In which situation would the nurse withhold the feeding and notify the health care provider? 1. Apical heart rate 120-130 2. Axillary temperature 97.2°F-98.4°F 3. Yellow tint to skin and sclera 4. Respiratory rate 62-68
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Answer: 4 Rationale: Any sustained respiratory rate greater than 60 breaths/minute increases the risk of aspiration in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease the risk of aspiration. An apical heart rate of 120-130 is a normal finding. Although an infant temperature of 97.2°F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice may be considered abnormal but it alone would not be an indication to withhold an oral feeding. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is identification of abnormal findings that would contraindicate feeding. The correct answer would be the option that contains an abnormal finding related to a condition that could be exacerbated by feeding. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 757-758.
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A newborn's mother has a history of prenatal narcotic abuse. Which interventions would be most appropriate for the infant of a substance abusing mother (ISAM) in the immediate postpartum period? Select all that apply. 1. Monitor the weight every eight hours. 2. Offer infant a pacifier. 3. Assess blood glucose levels. 4. Allow breastfeeding if alcohol is the addiction. 5. Keep the infant in high-Fowler's position.
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Answer: 1, 2, 3, 4 Rationale: Infants experiencing neonatal abstinence syndrome (NAS) have needs immediately after birth that change as the hours pass. These infants need frequent weights as intake may be diminished due to withdrawal symptoms. It may be helpful to the infant to be offered opportunity for nonnutritive sucking, such as with a pacifier to soothe and quiet the infant. These infants are at high risk for glucose abnormalities, making glucose monitoring important. Breastfeeding is allowed if the mother is addicted to alcohol but she must not breastfeed after alcohol ingestion. It is unnecessary to keep the infant in high-Fowler's position. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is a newborn experiencing abstinence syndrome, a condition associated with hyperstimulation. The correct answer(s) would be options that reduce stimulation and quiet the infant. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 735-737.
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The nurse is caring for a preterm infant who is at risk for an intraventricular hemorrhage (IVH). Which assessment is most critical for this infant? Select all that apply. 1. Increasing head circumference 2. Sudden drop in hemoglobin 3. Pink skin with blue extremities 4. "Waxy" skin color with rapid onset 5. Intake and output
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Answer: 1, 2, 4 Rationale: A frequent sign of IVH is an increase in head circumference, since the cranial bones have not fused and can separate as the bleed accumulates in the cranium. A sudden drop in hemoglobin can be indicative of IVH. A change in skin color to a 'waxy' appearance can occur with drop in hemoglobin. Pink skin with blue extremities is not indicative of an IVH. Intake and output are routine measurements that are not directly helpful in this situation. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is intraventricular hemorrhage. Evaluate each option and choose those that are consistent with blood loss into the cranium. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 716.
