Question 1

A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support.  The client's parents have repeatedly asked when their child will be able to breathe without the ventilator.  Which action by the nurse is appropriate?

Accepted Answer

Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care (Option A). (Option B) The nurse should not notify parents of genetic test results; this is the responsibility of the HCP. Information regarding the newborn's condition may be provided after the HCP notifies the parents of test results. (Option C) There is no cure for a newborn with trisomy 18 because it is a chromosomal abnormality. (Option D) The nurse should be sensitive toward the parents and provide accurate information. Telling the parents that their newborn might live long enough to go home is inappropriate because it gives them false hope, as this possibility occurs in only a small number of newborns with trisomy 18. Educational objective: Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality. Many of those affected will die in the first week of life and most do not make it to the first birthday. The nurse should request a collaborative meeting between the health care providers and the palliative care team to help the parents understand their infant's condition and make decisions.

Question 2

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up?

Accepted Answer

11ecbb05_cc19_dc65_b433_6d63c7340f47_MD0009_00 Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required (Option C). (Option A) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. (Option B) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). (Option D) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns. Educational objective: Spina bifida is a neural tube defect that occurs when spinal vertebrae do not close during fetal development, potentially allowing spinal cord contents to protrude through the opening. A tuft of hair, hemangioma, nevus, or dimple at the base of the spine may indicate the mildest form, spina bifida occulta.

Question 3

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position.  The nurse clears the airway, dries, and stimulates the newborn.  At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min.  What action should the nurse take?

Accepted Answer

11ecbb05_cc13_2598_b433_cff40f588713_MD0009_00 Newborns are evaluated immediately after birth for adaptation to extrauterine life. Newborns requiring resuscitative measures should be cared for using structured, evidence-based interventions, such as the neonatal resuscitation program (NRP) algorithm. Each step of the NRP algorithm requires rapid assessment and decision-making at 30-second intervals. NRP dictates that positive pressure ventilation (PPV) be started when a newborn's heart rate is <100/min. Effective PPV will often result in a rising heart rate and return of spontaneous respirations. (Option A) Epinephrine is administered after chest compressions, if the heart rate remains < 60/min. (Option C) The newborn has already been stimulated for 30 seconds, and placed in the optimal "sniffing" position. The next step is initiation of PPV if the heart rate remains <100/min. (Option D) Chest compressions are started after at least 30 seconds of quality PPV, if the newborn's heart rate remains <60/min. The landmark for compressions is the middle third of the sternum just below an imaginary line drawn between the nipples. Either the two-finger, or two-thumb technique may be used for newborn chest compressions. Educational objective: Neonatal resuscitation interventions after birth are initiated at 30-second intervals, with continual assessment of the newborn's adaptation to extrauterine life. Positive pressure ventilation (PPV) is started if heart rate is <100/min; compressions are started if the newborn's heart rate remains <60/min after at least 30 seconds of quality PPV.

Question 4

A nurse is teaching a postpartum client about cord care for the newborn.  Which statement by the client indicates a need for further teaching?

Accepted Answer

11ecbb05_cc16_f632_b433_0733eb34a722_MD0009_00 Proper care of the umbilical cord stump facilitates healing and reduces infection and bleeding risks. The primary goal of cord care is to keep the cord stump clean and dry, which reduces infection risk. Additional teaching points regarding cord care include: Keep the cord stump open to air when possible to allow for adequate drying. Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump (previously common practice); current recommendations are to avoid such solutions due to the potential for skin irritation (Option C). Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. (Option A) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days. cord stump (Option B) The cord usually separates spontaneously from the umbilicus 1-2 weeks after birth. Parents should be instructed not to pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications. (Option D) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.

Question 5

The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply.

Accepted Answer

Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further intervention. Unexpected findings in newborns include: Decreased muscle tone (ie, hypotonia), which may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury (Option B). Newborns normally have increased muscle tone and should resist movement of the extremities. Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally (Option D). Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart (Option E). Normal umbilical cords contain 2 arteries and 1 vein. (Option A) Bluish discoloration of the hands, feet, and around the mouth (ie, acrocyanosis) is a common, harmless finding during the first 24 hours after birth and through the first week of life when exposed to cold. (Option C) The normal heart rate for a newborn is 110-160/min when awake and calm. However, the heart rate may further range from 80/min during rest to 180/min when crying or agitated. Educational objective: Nurses assessing newborn clients should monitor closely for abnormal findings that may require further intervention. Some abnormal findings in a newborn include decreased muscle tone, sacral dimple, and a single artery in the umbilical cord. Bluish discoloration of the hands, feet, and lips and heart rate of 110-160/min are normal physiologic variations in newborns.

Question 6

The nurse is caring for a 6-hour-old, full-term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. What is the nurse's first action?

Accepted Answer

Poorly controlled diabetes mellitus during pregnancy exposes the fetus to high blood glucose (BG) levels. This results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and storage of fat (macrosomia). Immediately after birth, transient hyperinsulinemia and sudden cessation of the maternal glucose supply put the newborn at risk for hypoglycemia. Although there is no standard definition for newborn hypoglycemia, a normal range for serum BG in a newborn age <24 hours is 40-60 mg/dL (2.2-3.3 mmol/L), and a low BG is <40-45 mg/dL (<2.2-2.5 mmol/L). If a newborn has a low BG and is asymptomatic, immediate feeding with formula or breast milk should begin to increase BG and prevent further hypoglycemia (Option A). (Option B) If the newborn is symptomatic or BG levels remain <40-45 mg/dL (2.2-2.5 mmol/L) after feeding, the nurse should notify the health care provider and prepare to administer IV glucose. (Option C) Although cold stress may cause hypoglycemia, feeding and keeping the newborn warm via skin-to-skin contact are priorities. (Option D) Newborns who have hypoglycemia and are symptomatic (eg, poor feeding, jitteriness, irritability) or those whose BG is not increased through feeding require IV glucose administration. Educational objective: Hypoglycemia occurs commonly in newborns of mothers with diabetes due to elevated insulin levels and consumption of stored glucose. Common signs include poor feeding, jitteriness, and irritability. Asymptomatic newborns with low blood glucose (<40-45 mg/dL [2.2-2.5 mmol/L]) should be fed breast milk or formula immediately.

Question 7

The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply.

Accepted Answer

When caring for newborns, the nurse should recognize abnormal findings and report them to the health care provider. Some abnormal newborn findings include: Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment (Option A). Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and progress to the trunk and extremities (Option D). Although newborn jaundice after 24 hours of life is usually physiologic and resolves spontaneously, it should still be reported and monitored closely to ensure resolution. No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration (Option E). (Option B) Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days. (Option C) Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference may indicate an abnormal condition (eg, microcephaly, hydrocephalus). Educational objective: When caring for newborns, the nurse should recognize abnormal findings (eg, jaundice, failure to void within 24 hours, signs of respiratory distress [eg, chest wall retractions]), and report them to the health care provider for further assessment.

Question 8

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn.  Circumcision was performed using the clamp method.  Which statement by the client demonstrates a need for further teaching?

Accepted Answer

Newborn circumcision is a procedure that removes the foreskin from the glans penis using a clamp (eg, Gomco) or plastic ring (eg, PlastiBell). Circumcision is typically performed near discharge to ensure that the newborn is stable. Circumcision care includes: Washing hands before providing care. Applying petroleum jelly to the glans penis at diaper changes (unless PlastiBell was used) for 3-7 days to prevent the exposed glans from adhering to the diaper until the site heals. The circumcision site typically heals within 7-10 days. Expecting yellow exudate on the penis after the first day, a normal part of the healing process (Option D). Exudate should not be removed forcefully and disappears in 2-3 days. Swelling, increasing redness, odor, or abnormal discharge may indicate infection. (Option A) Bleeding that exceeds the size of a quarter is a concern. (Option B) Using warm water (without soap) to remove urine/feces during diaper changes or at least twice daily is needed to keep the site clean. Alcohol-based wipes prevent healing and cause discomfort. (Option C) In the first 48 hours of life, 2-6 wet diapers every 24 hours are expected. By 3-4 days, 6-8 wet diapers every 24 hours are expected. The nurse should notify the health care provider if there is inadequate voiding or no voiding within 6-8 hours of circumcision, which may indicate urethral damage or excessive swelling. Educational objective: Yellow exudate on the glans penis indicates normal healing. Unusual swelling, increasing redness, odor, abnormal discharge, excessive bleeding, or absent/decreased urine output should be reported.

Question 9

The nurse is performing an Apgar assessment on a newborn client at 1 minute of life.  The newborn is completely blue, has a heart rate of 110/min, and is emitting a weak cry.  Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned.  Which Apgar score should the nurse assign this newborn?

Accepted Answer

11ecbb05_cc13_73b9_b433_0d7b0dba6976_MD0009_00 The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Apgar scoring is done at 1 and 5 minutes of life. Apgar scores do not predict future neurologic outcomes, nor should assigning Apgar scores delay the decision to initiate resuscitation. An Apgar score of 6 at 1 minute of life is appropriate for a newborn with the following findings: Completely blue (0 points for appearance/color of skin) Heart rate >100/min (2 points for pulse) Grimaces during stimuli (eg, nasal suction) (1 point for grimace/reaction) Actively moves with good tone (ie, flexion of arms and legs) (2 points for activity/muscle tone) Emits a weak cry (1 point for respiratory effort) Apgar scoring is repeated every 5 minutes for up to 20 minutes if the 5-minute Apgar score is <7. Scores <7 indicate difficulty transitioning and may require further interventions (eg, oxygen, suctioning) in addition to typical supportive measures (eg, stimulating, drying, warming). (Options A and B) An Apgar score of 4 or 5 is too low for a newborn with these findings. (Option D) An Apgar score of 8 is too high for a newborn with these findings. Educational objective: The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Scores are assigned at 1 and 5 minutes of life. If the 5-minute Apgar score is <7, it is repeated every 5 minutes for up to 20 minutes.

Question 10

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention?

Accepted Answer

Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection (Option D). The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes. (Option A) Common characteristics of normal newborn respiratory patterns may include shallow, irregular, or abdominal respirations. (Option B) The apical heart rate should be counted for a full minute and is normally 100-180/min. Stimulated states (eg, crying, activity) may cause increased heart rate, respirations, and blood pressure. The nurse should reassess vital signs when the newborn is calm. (Option C) A physiologic heart murmur is expected in the first 48 hours of life during transition from fetal to neonatal circulation. Newborns with congenital heart disease have a pathologic heart murmur associated with other assessment findings (eg, abnormal vital signs, cyanosis, poor feeding). Educational objective: The normal respiratory rate and pattern for newborns is 30-60/min with periodic pauses lasting <20 seconds. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs, meconium aspiration, or infection.

Question 11

A nurse is assessing a newborn with an infection due to Candida albicans.  Which assessment data support this diagnosis?

Accepted Answer

Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches are nonremovable and tend to bleed when touched. The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide (eg, nystatin) may hasten recovery. (Option A) Erythema toxicum neonatarum is characterized by firm, white or yellow papules or pustules surrounded by erythema. This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days. There are no additional systemic effects, and the rash requires no treatment. (Option B) Epstein pearls are small, white cysts found on the hard palate of newborns. These cysts are considered common findings, and they disappear a few weeks after birth. (Option C) Vesicular skin lesions could be from an infection caused by varicella-zoster virus (chickenpox) or Staphylococcus aureus (impetigo). These lesions are not associated with a fungal infection. Educational objective: Oral candidiasis (thrush) is a fungal infection. Manifestations include white patches on the oral mucosa, palate, and tongue, and difficulty sucking or feeding. The patches are nonremovable and tend to bleed when touched.

Question 12

Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply.

Accepted Answer

A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns. This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which correlates to an estimation of gestational age. Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body (Option A). The 28-week newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat (Option D). The areolae of extremely premature infants may be barely visible, with no raised breast buds (Option C). Palpable, raised breast buds measuring 5-10 mm would be expected in newborns closer to term gestation. (Option B) At 28 weeks gestation, a newborn's feet have very smooth soles with only faint red marks or possibly a single anterior transverse crease. Creases over the entire sole and/or peeling skin would be expected in a full- or post-term (ie, 40+ weeks) newborn. (Option E) The testes of a male infant born at 28 weeks gestation would not yet have descended into the scrotal sac and may be palpable in the upper inguinal canal. Educational objective: A gestational age assessment assists the nurse in providing developmentally appropriate care for preterm newborns. The newborn at 28 weeks gestation has abundant lanugo; flat areolae without palpable breast buds; and smooth, pink skin with visible veins.

Question 13

The nurse is teaching a class of expectant parents about infant safety.  Which statement by a class participant indicates a need for further instruction?

Accepted Answer

11ecbb05_cc18_a3e3_b433_9bf771de2184_MD0009_00 Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses should inform caregivers about childcare practices that reduce the risk of SIDS, including: Place infant on the back to sleep on a firm surface every time. Infants should not share a bed with anyone. Avoid soft objects (eg, stuffed animals, pillows) in the infant's bed. Nothing in the bed with the infant is safest. Avoid bumper pads for the crib. Newer cribs do not require bumper pads because improved side rails prevent the infant's head from getting stuck between slats (Option D). Maintain a smoke-free environment. Avoid overheating. Infants do not require more than one extra layer than adults require to be comfortable. Breastfeed and ensure immunizations are updated. (Option A) Using a pacifier during sleep is appropriate and has been associated with a reduced incidence of SIDS. Pacifiers should be delayed until after breastfeeding is well established. (Option B) A sleeper ("onesie") or a sleeping sack and a comfortable room temperature reduce the need for a blanket, which could obstruct the infant's mouth and/or nose. (Option C) Infants should sleep on a firm surface or mattress that fits the crib and is covered with a fitted sheet. Educational objective: To reduce the risk of sudden infant death syndrome, infants should always be placed in their own bed, on their backs, and on a firm surface without loose bedding or toys. Prevention also includes a smoke-free environment, breastfeeding, pacifiers, avoidance of overheating, and immunizations.

Question 14

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply.

Accepted Answer

11ecbb05_cc14_d350_b433_19869b134678_MD0009_00 A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option C). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option E). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option B). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option A) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option D) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Educational objective: Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20-30 minutes, using special nipples or bottles, and feeding every 3-4 hours. The infant should be burped at regular intervals to reduce gastric distension.

Question 15

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response?

Accepted Answer

According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood. Taking-in: In the first 24-48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is more dependent on the health care team to help with care of the baby. Taking-hold: During 2-10 days postpartum, the mother still is learning the technical skills of mothering but may feel inadequate. Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role. Research indicates that new mothers adapt to their role today more quickly than they did during the 1960s, when the Rubin theory was developed. This mother is still learning to care for the newborn. Therefore, letting her change the diaper will allow the nurse to assess her diaper changing skills and provide education as needed. (Option A) If the nurse takes over this essential task and delays the client's need to be comfortable in the role of a mother, it may reinforce the client's perception of not being capable or competent. (Option C) This response would give the mother opportunity to demonstrate the new skill, but it is not a good example of therapeutic communication. (Option D) The mother was taught how to change a diaper the previous day. If the nurse performs the task, the mother may feel incompetent and unable to learn. Educational objective: There are 3 distinct phases of postpartum adjustment to motherhood, as outlined by Rubin. 11ecbb05_cc13_e8ea_b433_2bd864c071bc_MD0009_00

Question 16

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet.  The trunk has a pink color.  Which action by the nurse is appropriate?

Accepted Answer

Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold. Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth. Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-to-skin with the mother or under a radiant warmer and assessing axillary temperature (Option D). (Option A) Acrocyanosis is considered normal during the first day of life. Therefore, supplemental oxygen is not warranted unless central cyanosis or other signs of respiratory distress (eg, tachypnea) occur. (Option B) Transient acrocyanosis without central cyanosis in the first day of life is considered normal and not indicative of a pathologic condition (eg, murmur). (Option C) Because peripheral cyanosis is a normal finding associated with the newborn's inability to retain heat adequately, the best action is to facilitate newborn thermoregulation and continue routine observation for any respiratory abnormalities. Educational objective: Acrocyanosis manifests as a bluish discoloration of the newborn's hands and feet; it is considered a normal finding during the first day of life or if the newborn becomes cold. The best nursing action is to promote warmth by placing the newborn skin-to-skin with the mother.

Question 17

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding?

Accepted Answer

Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems; they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake. Clinical manifestations of cold stress include: Neurological - altered mental status (irritability or lethargy) (Option A) Cardiovascular - bradycardia Respiratory - tachypnea early, followed by apnea and hypoxia Gastrointestinal - high gastric residuals, emesis, hypoglycemia (Option B) Musculoskeletal - hypotonia, weak suck and cry (Option D) Educational objective: Premature infants are at high risk for cold stress due to decreased brown adipose tissue and inability to generate heat by shivering. The nurse should carefully assess for signs of cold stress, which include decreased temperature, altered mental status, bradycardia, hypoxia, hypotonia, and a weak cry and/or suck.

Question 18

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy?

Accepted Answer

11ecbb05_cc19_8e44_b433_89e4ff16cb2d_MD0009_00 Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine. The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and breakdown. (Option A) Allowing parents to feed the newborn promotes bonding. The newborn should not be removed from the lights except during feedings for optimal effect of the phototherapy. Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration from phototherapy. (Option C) Temperature should be monitored closely, with the incubator placed on a low-heat setting. (Option D) The newborn's eyes should be covered with patches or guards to prevent retinal damage or cataracts when under the phototherapy lights. Educational objective: The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output.

Question 19

A nurse is preparing to teach the parents of a newborn about newborn safety.  Which instruction is appropriate for the nurse to include in the teaching plan?

Accepted Answer

11ecbb05_cc16_59f1_b433_6f65194165b3_MD0009_00 Principles of newborn safety should be reinforced during postpartum discharge teaching. The following safe sleep practices help prevent sudden infant death syndrome: Dress newborns in no more than one more layer of clothing than an adult requires. A wearable blanket (ie, sleep sack) can keep the newborn warm and prevents the head from being covered (Option A). Always place the newborn in the supine position during sleep (Option C). Ensure no loose bedding or other objects are in the crib (eg, blankets, stuffed toys, pillows). Prevent newborn head entrapment by ensuring crib slats are no more than 2¼ inches (5.72 cm) apart. Essential teaching for proper car safety seat use includes: Secure the safety seat harness to fit snuggly against the newborn's body, with the retaining clip secured near the level of the armpits. No bulky jackets or blankets should be between the newborn and the harness because this would reduce its effectiveness during a crash (Option B). Place the newborn in a federally approved, rear-facing car seat secured in the back seat (Option D). Position the newborn at a 45-degree angle to prevent airway obstruction. Rolled blankets/car seat inserts on both sides/under the crotch strap may be used to prevent slouching. Educational objective: Newborn safety teaching should include use of a newborn sleep sack, which keeps the newborn warm while preventing the head from becoming covered; supine sleep position; no loose bedding; and proper car safety seat use (eg, snuggly fitted harness, rear-facing, back seat).

Question 20

The nurse is caring for a postpartum couplet and notices that the newborn is cyanotic and apneic, with a heart rate of 70/min.  The nurse calls for help and begins resuscitation.  Which position is appropriate for ventilating the newborn?

Accepted Answer

11ecbb05_cc14_852f_b433_612786e0359e_MD0009_00 Before newborn resuscitation, the nurse should place the infant on the back with the neck slightly extended to promote adequate ventilation. Very slight neck extension, otherwise known as the neutral or sniffing position, ensures a patent airway. The nurse may need to place a blanket or towel roll under the newborn's shoulders to elevate the chest ¾-1 inch (2-2.5 cm) above the mattress. This technique may be particularly useful for maintaining the sniffing position during ventilation if the newborn has a large occiput from molding or edema (eg, caput succedaneum) (Option A). (Option B) The newborn's neck is not well extended and slightly flexed, which can decrease air entry. (Option C) The newborn's neck is hyperextended, which can decrease air entry. (Option D) A blanket or towel roll under the newborn's occiput results in significant neck flexion and decreases air entry. Educational objective: Before newborn resuscitation, the nurse should position the newborn with the neck slightly extended (ie, sniffing position) to allow proper air entry into the lungs during ventilation. In addition, a blanket or towel roll placed under the newborn's shoulders may facilitate positioning.

Exam 6: Maternal & Newborn Health

A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support. The client's parents have repeatedly asked when their child will be able to breathe without the ventilator. Which action by the nurse is appropriate?

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up?

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching?

The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply.

The nurse is caring for a 6-hour-old, full-term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L) . The newborn is asymptomatic. What is the nurse's first action?

The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply.

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching?

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention?

A nurse is assessing a newborn with an infection due to Candida albicans. Which assessment data support this diagnosis?

Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply.

The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply.

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate?

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding?

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy?

A nurse is preparing to teach the parents of a newborn about newborn safety. Which instruction is appropriate for the nurse to include in the teaching plan?

The nurse is caring for a postpartum couplet and notices that the newborn is cyanotic and apneic, with a heart rate of 70/min. The nurse calls for help and begins resuscitation. Which position is appropriate for ventilating the newborn?