fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam [Valium], oxytocin [Pitocin], sulfisoxazole/erythromycin [Pediazole], and chloramphenicol [Chloromycetin]), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth, resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, intrauterine infections such as TORCH (toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes simplex viruses), and Asian or Native American ethnicity biliary obstruction (biliary atresia, gallstones, neoplasm), sepsis, hepatitis, chromosomal abnormality (Turner syndrome, trisomies 18 and 21), and drugs (aspirin, acetaminophen, sulfa, alcohol, steroids, antibiotics). convection Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. An example of convection-related heat loss would be a cool breeze that flows over the newborn. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Evaporation involves the loss of heat when a liquid is converted to a vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Drying newborns immediately after birth with warmed blankets and placing a cap on their head will help to prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps to prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction. yellow-green, pasty, unpleasant-smelling stool The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool. -More common than cocaine use in pregnancy Sets with similar termsThe nurse determines a newborn is small-for-gestational age based on which characteristics? a. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores The nurse determines a newborn is small-for-gestational age based on which characteristics? A. wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? a. 20th a. 20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight. What is a consequence of hypothermia in a newborn? a. respirations of 46 c. holds breath 25 seconds 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. A nurse is providing care to a large-for-gestational-age newborn. The newborn's blood glucose level was 32 mg/dl one hour ago. Breastfeeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dl. Which action would the nurse do next? a. Administer intravenous glucose. a. Administer intravenous glucose Supervised breastfeeding or formula feeding may be the initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. If hypoglycemia persists, then intravenous dextrose may be needed. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dl. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? a. Deep inspiration c. Sternal retraction The nurse should identify 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. A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? a. meconium aspiration in utero or at birth a. meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are post term. 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. A client with diabetes gives birth to a full-term neonate who weights 10 lb, 1 oz (4,600 g). While caring for this large-for-gestational-age (LGA) neonate, the nurse palpates the clavicles for which reason? a.
Neonates of mothers with diabetes have brittle bones. c. One of the neonate's clavicles may have been broken during birth. Because of the neonate's large size, clavicular fractures are common during birth. The nurse should assess all LGA neonates for this occurrence. None of the other options are true. The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? a. The skin is pale, and no vessels show through it. c. The pinna of the ear is soft and flat and stays folded. The ear has a soft pinna that is 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. A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What 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 a. Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute 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. A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? a. term, small-for-gestational-age, and low-birth-weight infant a. term, small-for-gestational-age, and low-birth-weight infant 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 post term, 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 (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW). A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?
a. Tip the infant into an upright position a. Tip the infant into an upright position 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. A large-for-gestational age newborn has a blood glucose level of 30 mg/dl and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next? a. Encourage frequent feedings. a. Encourage frequent feedings Symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. Glucose water is not indicated. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate? a. The infant was a preterm, low-birth-weight and small-for-gestational-age a. The infant was a preterm, low-birth-weight and small-for-gestational-age Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate. Which condition may cause intrauterine asphyxia? Select all that apply. a. cord compression a. cord compression Conditions such as cord compression, placental abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor. The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant? a. Blood flows from the pulmonary vein to the alveoli. c. Blood flows from the aorta to the pulmonary artery. Inadequate respiratory effort results in hypoxia. During hypoxia, the ductus arteriosus does not close, resulting in blood flow from the aorta to the pulmonary artery and inadequate pump action of the heart. The pulmonary vein takes blood from the right ventricle to the lungs. The foramen ovale allows blood flow from right atrium to left atrium during fetal life and is not primarily impacted by hypoxia. Oxygenated blood flows from the lungs to the left ventricle to be pumped to the body A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag? a. the blow-off valve, which limits the pressure in the apparatus d. the pressure the nurse uses when the hand squeezes against the bag The pressure exerted by the nurse's hand squeezing the bag controls the pressure delivered by an anesthesia bag. An ambu or resusci bag has a blow-off value that limits the pressure administered. How does the nurse position the infant experiencing respiratory difficulty? a. on the back with the head elevated 15 degrees a. on the back with the head elevated 15 degrees Positioning the infant on the back allows bilateral lung expansion. Elevating the head 15 degrees enhances movement of the diaphragm. Positioning the infant on the side or on the stomach restricts lung expansion. What action by the nurse provides the neonate with sensory stimulation of a human face? a. encouraging the mother to view the baby through the isolette dome b. assisting the mother to position the infant in an en face position To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly. A full-term infant with spontaneous respiration at birth begins exhibiting signs of respiratory distress syndrome (RDS) at 22 hours of age. Which condition would the nurse assess for in this infant? a. meconium aspiration syndrome d. Group B streptococcus (GBS) infection A group B streptococcal infection may mimic RDS because this infection is so severe in newborns that it stops surfactant production. Meconium aspiration syndrome would be preceded by the presence of meconium in the amniotic fluid at birth. A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? a. "We will call 911 if we start to see that our newborn's lips or
skin are looking bluish." b. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours. A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess? a. head larger than
body a. head larger than body A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. 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) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body. The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor? a. inability to clear fluids c. deficiency of surfactant A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea of the newborn. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction. The mother of a preterm infant tells her nurse that she would like to visit her newborn in the neonatal intensive care unit (NICU). Which response by the nurse would be most appropriate? a. "Certainly. You will need to wash your hands and gown before you can hold him, however." a. "Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should 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 will help make the child's birth more real to them. The nurse weighs the new infant and calculates the child's measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA. What does that mean? "What is the nurse's best response? a. "That means that your baby is lazy sometimes." c. "That means your baby is over the 90th percentile for weight." 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. A preterm infant is transferred to a distant hospital for care. When her parents visit her, which action would be most important for the nurse to urge them to do? a. Call the baby by her name. b. Touch and, if possible, hold her. 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. An 18-year-old client has given birth at 28 weeks' gestation and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS? a. Glucocorticoid (GC) is given
to the newborn following birth. b. RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticoid, 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, not improve, within a short period of time after birth. 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).
A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: a. inspiratory stridor. b. expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen). A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the neonate is being born. Which intervention should the nurse implement as a result of this finding? a. Provide supplemental oxygen and monitor respiratory status a. Provide supplemental oxygen and monitor respiratory status When the amniotic fluid is stained greenish black, the neonate is at risk for meconium aspiration syndrome (MAS). Treatment for MAS depends on severity, but standard guidelines include supplemental oxygen and close monitoring of respiratory status. Additional treatment depends on the severity of respiratory compromise. The health care provider would determine if additional treatment is needed. The nurse should not administer oxygen under pressure (bag and mask) until the neonate 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 neonate and flicking the sole of the foot are methods of stimulating breathing in a neonate experiencing apnea. A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment? a. The infant may have excess of lanugo
and vernix caseosa. d. The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks' 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. What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a. heart rate as normal b. respirations as increased and high Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as: a. postterm d. full term A full term newborn is one born from the first day of the 38th week of gestation through 41 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 born between 34 and 36 6/7 weeks' gestation. If the nurse manages a newborn with low blood sugar, which intervention would be appropriate to prevent hypoglycemia? a. Hold all feedings. c. Feed the neonate. The newborn could be fed either breast milk or formula to prevent low blood sugar. If unable to feed well, the neonate can receive intravenous fluids. The other choices do not raise blood sugar. The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? a. Suggest that the parents stay for just a few minutes to reduce their anxiety. c. Encourage the parents to touch their preterm newborn. The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated. An infant who is diagnosed with meconium aspiration displays which symptom? a. intercostal and substernal retractions a. intercostal and substernal retractions Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia. A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? a. substance use disorder b. diabetes Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth. Which finding is indicative of hypothermia of the preterm neonate? a. regular respirations d. nasal flaring Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings. When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a. evaporation d. conduction A conduction heat loss results from direct contact with an object that is cooler. A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a. assists with ciliary body maturation in the upper airways d. helps the lungs remain expanded after the initiation of breathing 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 has not been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern. The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? a. The newborn is placed on the back to sleep. a. The newborn is placed on the back to sleep. Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS. A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is at risk for which complication? a.
anemia b. hypoglycemia 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 cannot 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 are not at increased risk for anemia, nitrogen loss, or thrombosis. In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a. Ineffective parental attachment c. Impaired tissue perfusion Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues. A newborn that has a surfactant deficiency will have which assessment noted on a physical exam? a. regular respirations d. grunting Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling. At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? a. postterm a. postterm These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat. A newborn with high serum bilirubin is receiving phototherapy. Which is the most appropriate nursing intervention for this client? a. Application of eye dressings to the infant a. Application of eye dressings to the infant 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. |
What action by the nurse provides the neonate with sensory stimulation of a human face quizlet?
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