Newborn Care

STUDY
PLAY
A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?
1
Color
2
Heart rate
3
Respirations
4
Reflex irritability
A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?
Correct1
Color
2
Heart rate
Incorrect3
Respirations
4
Reflex irritability
Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color. This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points.
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?
1
Protecting the sac with moist sterile gauze
2
Removing buccal mucus and administering oxygen
3
Placing name bracelets on both the mother and infant
4
Transferring the newborn to the neonatal intensive care unit
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?
Correct1
Protecting the sac with moist sterile gauze
2
Removing buccal mucus and administering oxygen
3
Placing name bracelets on both the mother and infant
Incorrect4
Transferring the newborn to the neonatal intensive care unit
Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.
After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed?
1
Monitoring of cardiac status
2
Assessment of neurological reflexes
3
Ensuring increased caloric intake and fluids
4
Administration of respiratory support and observation
After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed?
1
Monitoring of cardiac status
Incorrect2
Assessment of neurological reflexes
3
Ensuring increased caloric intake and fluids
Correct4
Administration of respiratory support and observation
The Silverman-Anderson score is an index of neonatal respiratory distress. A Silverman-Anderson score of 6 does not reflect cardiac function, neurological status, or caloric need.
Respiratory distress syndrome (RDS) develops in a neonate born at 33 weeks' gestation 6 hours after birth. What would the nurse's assessment of the newborn at this time reveal?
1
High-pitched cry
2
Intercostal retractions
3
Respirations of 30 breaths/min
4
Heart rate of 140 beats/min
Respiratory distress syndrome (RDS) develops in a neonate born at 33 weeks' gestation 6 hours after birth. What would the nurse's assessment of the newborn at this time reveal?
1
High-pitched cry
Correct2
Intercostal retractions
Incorrect3
Respirations of 30 breaths/min
4
Heart rate of 140 beats/min
Intercostal retractions are a classic sign of respiratory distress in the newborn. A high-pitched cry is associated with neurologic impairment, not respiratory distress. The lowest respiratory rate of a healthy, resting newborn is 35 breaths/min. With RDS the rate increases, not decreases. Heart rate of 140 beats/min is within expected limits.
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
1
Promote the synthesis of prothrombin
2
Facilitate the growth of intestinal flora
3
Limit an increase in the serum bilirubin level
4
Decrease the level of calciferol until the kidneys have matured
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
Correct1
Promote the synthesis of prothrombin
Incorrect2
Facilitate the growth of intestinal flora
3
Limit an increase in the serum bilirubin level
4
Decrease the level of calciferol until the kidneys have matured
Vitamin K stores are almost absent in the newborn because the intestinal flora that produce this vitamin are not present; vitamin K is an essential precursor of prothrombin, which is part of the clotting mechanism. The intestinal flora develop as the newborn is exposed to extrauterine living conditions. An increased serum bilirubin level may occur in the newborn because of the rapid breakdown of red blood cells and the immature liver's inability to conjugate such large amounts; it is not related to vitamin K. A newborn's kidneys operate at a functional level appropriate to the needs of a healthy newborn, and kidney maturity and calciferol are not related to vitamin K.
While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding, what information should the nurse consider?
1
Flat feet are common in children, requiring them to wear orthotic shoes.
2
The newborn's feet are so small that it is difficult to determine whether there is an arch.
3
Flat feet are associated with deformities of the bones of the feet such as clubfoot.
4
The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat.
While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding, what information should the nurse consider?
1
Flat feet are common in children, requiring them to wear orthotic shoes.
Incorrect2
The newborn's feet are so small that it is difficult to determine whether there is an arch.
3
Flat feet are associated with deformities of the bones of the feet such as clubfoot.
Correct4
The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat.
Newborns and infants have fat pads where the arch should be; the arch develops when the toddler begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant. Flat feet are not associated with foot deformity.
When changing her newborn's diaper a new mother notes a reddened area on the infant's buttock and reports it to the nurse. What should the nurse do next?
1
Have nursery staff members change the infant's diaper.
2
Use both lotion and powder to protect the involved area.
3
Request that the practitioner prescribe a topical ointment.
4
Encourage the mother to cleanse the area and change the diaper more often.
When changing her newborn's diaper a new mother notes a reddened area on the infant's buttock and reports it to the nurse. What should the nurse do next?
1
Have nursery staff members change the infant's diaper.
2
Use both lotion and powder to protect the involved area.
Incorrect3
Request that the practitioner prescribe a topical ointment.
Correct4
Encourage the mother to cleanse the area and change the diaper more often.
Frequent cleansing and diaper changes will limit the presence of irritating substances. Having the nurses change the diaper may lower the mother's self-esteem. Powder and lotion will cake and retain moisture in the area. Requesting that the health care provider prescribe a topical ointment is a nursing, not a medical, problem.
A nurse is assessing a newborn with exstrophy of the bladder. What other defect associated with exstrophy of the bladder is of concern to the nurse?
1
Absence of one kidney
2
Congenital heart disease
3
Pubic bone malformation
4
Tracheoesophageal fistula
A nurse is assessing a newborn with exstrophy of the bladder. What other defect associated with exstrophy of the bladder is of concern to the nurse?
Incorrect1
Absence of one kidney
2
Congenital heart disease
Correct3
Pubic bone malformation
4
Tracheoesophageal fistula
Incomplete formation of the pubic bone is associated with exstrophy of the bladder. Absence of one kidney, congenital heart disease, and tracheoesophageal fistula are not associated with exstrophy of the bladder.
The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine?
1
1.0 mL subcutaneously before discharge
2
0.5 mL subcutaneously within 24 hours of birth
3
1.0 mL intramuscularly within 24 hours of birth
4
0.5 mL intramuscularly within 12 hours of birth
The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine?
1
1.0 mL subcutaneously before discharge
2
0.5 mL subcutaneously within 24 hours of birth
Incorrect3
1.0 mL intramuscularly within 24 hours of birth
Correct4
0.5 mL intramuscularly within 12 hours of birth
HBIG must be given within 12 hours of birth to be effective. The correct dose is 0.5 mL, and it must be given intramuscularly. The vaccine is not given subcutaneously.
While performing a newborn assessment for a male infant after a scheduled cesarean birth, the nurse notes that the infant's head circumference is 4 cm smaller than his chest circumference. What does this finding indicate?
1
It is an expected finding in a male newborn.
2
The infant's chest size is larger than average.
3
The infant's head size is smaller than average.
4
This finding is to be predicted after cesarean birth.
While performing a newborn assessment for a male infant after a scheduled cesarean birth, the nurse notes that the infant's head circumference is 4 cm smaller than his chest circumference. What does this finding indicate?
Incorrect1
It is an expected finding in a male newborn.
2
The infant's chest size is larger than average.
Correct3
The infant's head size is smaller than average.
4
This finding is to be predicted after cesarean birth.
The head's circumference is usually 2 cm larger than that of the chest; a head circumference 4 cm smaller than the chest may indicate microcephaly. According to growth charts, the range of head circumference for boys is just slightly (1.25 cm) larger than the chest. Molding does not occur with cesarean birth; therefore the head should be about 2.5 cm larger than the chest at birth. The expected ratio of head to chest circumference indicates that the chest is too small, not too large, for the head size.
preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents?
1
Fear of handling the infant
2
Delayed ability to bond with the infant
3
Prolonged hospital stay needed by the infant
4
Inability to provide breast milk for the infant
preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents?
Correct1
Fear of handling the infant
Incorrect2
Delayed ability to bond with the infant
3
Prolonged hospital stay needed by the infant
4
Inability to provide breast milk for the infant
Because these infants are so tiny and frail, parents most commonly fear handling or touching them; they should be encouraged to do so by the NICU staff. The primary concern is the infant's fragility, not bonding; however, bonding should be encouraged. Although there may be concerns about a long hospital stay, they are not commonly expressed by mothers. The primary concern is the infant's fragility, not breastfeeding. Breasts may be pumped and breast milk given in gavage feedings.
While changing her baby girl's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern?
1
Explaining that this is an expected finding
2
Obtaining a prescription for vaginal cultures
3
Assessing the infant for other signs of bleeding
4
Applying a urine specimen bag to the perineum
While changing her baby girl's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern?
Correct1
Explaining that this is an expected finding
2
Obtaining a prescription for vaginal cultures
Incorrect3
Assessing the infant for other signs of bleeding
4
Applying a urine specimen bag to the perineum
Vaginal discharge on the diaper is related to the influence of maternal hormones; it is temporary and is unrelated to problems with bleeding, infection, or urinary elimination.
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). What clinical finding confirms this complication?
1
Muscle irritability within 1 hour of birth
2
Neurologic signs during the first 24 hours
3
Jaundice that develops in the first 12 to 24 hours
4
Jaundice that develops between 48 and 72 hours after birth
A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). What clinical finding confirms this complication?
1
Muscle irritability within 1 hour of birth
2
Neurologic signs during the first 24 hours
Correct3
Jaundice that develops in the first 12 to 24 hours
Incorrect4
Jaundice that develops between 48 and 72 hours after birth
The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Neurologic signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL the second to third day when jaundice appears (physiologic jaundice).
For what finding should a nurse assess the newborn of a mother who is known to abuse opioids?
1
Dehydration
2
Hyperactivity
3
Hypotonicity of muscles
4
Prolonged periods of sleep
For what finding should a nurse assess the newborn of a mother who is known to abuse opioids?
1
Dehydration
Correct2
Hyperactivity
Incorrect3
Hypotonicity of muscles
4
Prolonged periods of sleep
As the opioid is cleared from the newborn's body, signs of withdrawal become evident. Tremors, irritability, difficulty sleeping, twitching, and convulsions result. Dehydration is a result of inadequate feeding; it is not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid exposure. Opioid withdrawal results in signs of excessive stimulation.
A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?
1
It prevents coagulation of blood during the neonatal period.
2
A newborn's liver does not produce it immediately after birth.
3
It prevents development of hyperbilirubinemia during the neonatal period.
4
A newborn's intestinal tract does not synthesize it for several days after birth.
A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?
Incorrect1
It prevents coagulation of blood during the neonatal period.
2
A newborn's liver does not produce it immediately after birth.
3
It prevents development of hyperbilirubinemia during the neonatal period.
Correct4
A newborn's intestinal tract does not synthesize it for several days after birth.
Because the infant's intestine is sterile at birth, it lacks the flora to synthesize vitamin K, which activates coagulation factors and prevents hemorrhage in the newborn. The liver does not produce vitamin K; vitamin K catalyzes the synthesis of prothrombin in the liver. Hyperbilirubinemia may develop because of complex factors; vitamin K cannot prevent this breakdown of red blood cells.
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
1
Changing diapers immediately when moist
2
Applying sterile, moist nonadherent dressings to the sac
3
Placing the infant in the reverse Trendelenburg position
4
Positioning the infant prone with the legs slightly adducted
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
1
Changing diapers immediately when moist
Correct2
Applying sterile, moist nonadherent dressings to the sac
Incorrect3
Placing the infant in the reverse Trendelenburg position
4
Positioning the infant prone with the legs slightly adducted
Applying sterile, moist nonadherent dressings is done to prevent drying and breakage of the sac; any opening increases the risk for infection of the central nervous system. Diapering is contraindicated until the defect is repaired; the diaper may irritate the sac and cause rupture, predisposing the infant to infection. The infant is generally placed in a neutral position to reduce pressure on the affected area. The legs are abducted to counteract subluxation because the infant is unable to move the legs.
What is the most appropriate way for the nurse to elicit the Moro reflex in an infant?
1
Stroking the sole of the infant's foot
2
Placing a finger in the infant's hand
3
Striking the surface of the infant's crib
4
Making a loud noise near the infant's head
What is the most appropriate way for the nurse to elicit the Moro reflex in an infant?
1
Stroking the sole of the infant's foot
2
Placing a finger in the infant's hand
Correct3
Striking the surface of the infant's crib
Incorrect4
Making a loud noise near the infant's head
Striking the surface of the infant's crib changes the infant's equilibrium and elicits the Moro reflex, a neurologic reaction, in infants younger than 6 months; the infant's movements should be bilateral and symmetric. Stroking the sole of the infant's foot is a test of the Babinski reflex, not the Moro reflex. Placing a finger in the infant's hand is a test of the grasp reflex, not the Moro reflex. Although the infant responds to a loud noise with the Moro reflex, it is a more appropriate test of the infant's hearing; a deaf infant will not respond to the noise.
As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. What infant behavior helps the nurse identify this problem?
1
Crying
2
Inhaling
3
Suckling
4
Sleeping
As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. What infant behavior helps the nurse identify this problem?
Correct1
Crying
Incorrect2
Inhaling
3
Suckling
4
Sleeping
Increased intraabdominal pressure associated with crying, coughing, or straining will cause protrusion of the hernia. Lowering of the diaphragm may increase intraabdominal pressure slightly but not enough to cause protrusion of an umbilical hernia. Suckling and sleeping do not increase intraabdominal pressure.
A nurse is assessing a newborn with caput succedaneum. What does the nurse tell the mother is the cause of this fetal condition?
1
Overlap of fetal bones as they pass through the maternal birth canal
2
Swelling of the soft tissue of the scalp as a result of pressure during labor
3
Hemorrhage of ruptured blood vessels that does not cross the suture lines
4
Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage
A nurse is assessing a newborn with caput succedaneum. What does the nurse tell the mother is the cause of this fetal condition?
Incorrect1
Overlap of fetal bones as they pass through the maternal birth canal
Correct2
Swelling of the soft tissue of the scalp as a result of pressure during labor
3
Hemorrhage of ruptured blood vessels that does not cross the suture lines
4
Accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage
Caput succedaneum is a diffuse pattern of edema above the periosteum; it results from an even distribution of pressure on the fetal head during labor. Overlap of fetal scalp bones is called molding, not caput succedaneum. Swelling that does not cross the suture line is cephalhematoma, not caput succedaneum; it occurs when the fetal head is pressing on the rim of the pelvis during the birthing process. Accumulation of fluid resulting from a partial blockage of cerebrospinal fluid is hydrocephalus; in hydrocephalus the circumference of the head is larger than expected.
Which sign indicates to the nurse that a neonate is preterm?
1
Flexion of extremities
2
Absent femoral pulses
3
Presence of Babinski reflex
4
Numerous superficial veins
Which sign indicates to the nurse that a neonate is preterm?
Incorrect1
Flexion of extremities
2
Absent femoral pulses
3
Presence of Babinski reflex
Correct4
Numerous superficial veins
Numerous superficial veins are observed in the preterm infant because of the lack of subcutaneous fat deposits. Flexion of the extremities is the posturing of a healthy term infant; a preterm infant usually postures with extremities extended and flaccid. An absence of femoral pulses is indicative of coarctation of the aorta, a congenital heart defect that is not related to gestational age. Presence of the Babinski reflex is expected in the full-term, not preterm, newborn.
A newborn is circumcised before discharge from the hospital. What should immediate postoperative care include?
1
Keeping the infant NPO for 4 hours to prevent vomiting
2
Encouraging the intake of alkaline fluids to reduce urine acidity
3
Changing the dressing using dry, sterile gauze to maintain cleanliness
4
Encouraging the mother to cuddle her baby to provide emotional support
A newborn is circumcised before discharge from the hospital. What should immediate postoperative care include?
1
Keeping the infant NPO for 4 hours to prevent vomiting
2
Encouraging the intake of alkaline fluids to reduce urine acidity
Incorrect3
Changing the dressing using dry, sterile gauze to maintain cleanliness
Correct4
Encouraging the mother to cuddle her baby to provide emotional support
Cuddling is comforting for the mother and baby and provides an opportunity to teach the mother how to take care of the circumcision. There is no contraindication to feeding the infant after the circumcision; nutrition may be withheld before, not after, the procedure. Providing alkaline fluids is inappropriate and could lead to fluid and electrolyte imbalance. Removal of dry gauze will cause bleeding; sterile petrolatum gauze is used and replaced with each diaper change.
While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?
1
Administer oxygen.
2
Offer an oral feeding.
3
Notify the practitioner.
4
Warm the environment.
While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?
Incorrect1
Administer oxygen.
2
Offer an oral feeding.
3
Notify the practitioner.
Correct4
Warm the environment.
Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
1
Examining for a cleft palate
2
Testing for congenital syphilis
3
Assessing the infant for muscle hypotonicity
4
Inspecting the soles for maculopapular lesions
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
1
Examining for a cleft palate
Correct2
Testing for congenital syphilis
3
Assessing the infant for muscle hypotonicity
Incorrect4
Inspecting the soles for maculopapular lesions
Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be screened immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester; Treponema pallidum does not affect a fetus before the 16th week of gestation. Muscle hypotonicity is found in children with Down syndrome, not those with congenital syphilis. Maculopapular lesions of the soles do not manifest in the infant with congenital syphilis until about 3 months of age.
After assessing a neonate who was delivered using forceps immediately after birth, the nurse confirms facial paralysis. Which information does the nurse provide to the mother?
1
Don't panic; it will resolve within a few days.
2
The neonate requires phototherapy for a few minutes.
3
Take the newborn to a neurologist immediately.
4
Refrain from breastfeeding the neonate for a few days.
After assessing a neonate who was delivered using forceps immediately after birth, the nurse confirms facial paralysis. Which information does the nurse provide to the mother?
Correct1
Don't panic; it will resolve within a few days.
2
The neonate requires phototherapy for a few minutes.
3
Take the newborn to a neurologist immediately.
Incorrect4
Refrain from breastfeeding the neonate for a few days.
Facial paralysis may occur in a neonate as a result of forceps delivery. This facial paralysis generally disappears within a few hours or days, so no medical intervention is required. Phototherapy does not affect facial paralysis in a neonate. Facial paralysis in a neonate generally does not reflect brain damage, so there is no immediate need to consult a neurologist. Breastfeeding is not contraindicated in neonates with facial paralysis.
A new mother is feeding her baby girl, who was born 36 hours ago in a spontaneous vaginal delivery. The nurse notices that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened to her?" What is the best response once the nurse has assessed the infant's head?
1
"Your baby's head is just slightly elongated, and that's nothing to be concerned about."
2
"She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now."
3
"Your baby may have a condition called cephalhematoma. It's common, but I'll make a note to have the pediatrician assess it."
4
"Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."
A new mother is feeding her baby girl, who was born 36 hours ago in a spontaneous vaginal delivery. The nurse notices that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened to her?" What is the best response once the nurse has assessed the infant's head?
1
"Your baby's head is just slightly elongated, and that's nothing to be concerned about."
2
"She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now."
Correct3
"Your baby may have a condition called cephalhematoma. It's common, but I'll make a note to have the pediatrician assess it."
Incorrect4
"Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."
A cephalhematoma usually develops on one side of the head over the parietal bones. The swelling is not generally present at birth; instead, it develops over the first 24 to 48 hours of life. Caput succedaneum appears over the vertex of the newborn's head and causes localized edema that varies in size. It is seen shortly after birth and resolves within 12 hours to several days after birth. Telling the mother not to worry dismisses her fears.
The nurse is assessing a female preterm neonate after delivery. Which assessment findings does the nurse document in the hospital reports of the infant? Select all that apply.
A
The infant has a prominent clitoris.
B
The sole of the infant is deeply creased.
C
The hair of the infant is fine and feathery.
D
The infant rests in a more flexed attitude.
E
The infant shows no resistance to the heel-to-ear maneuver.
The nurse is assessing a female preterm neonate after delivery. Which assessment findings does the nurse document in the hospital reports of the infant? Select all that apply.
CorrectA
The infant has a prominent clitoris.
B
The sole of the infant is deeply creased.
CorrectC
The hair of the infant is fine and feathery.
IncorrectD
The infant rests in a more flexed attitude.
CorrectE
The infant shows no resistance to the heel-to-ear maneuver.
A female preterm neonate lacks proper growth of the labia majora; therefore, the neonate will have a prominent clitoris. A preterm neonate lacks proper nourishment to the hair, resulting in fine and feathery hair. The knee of a preterm infant does not offer resistance to the heel-to-ear maneuver. The soles of a preterm infant's feet appear more turgid and may have only fine wrinkles. The preterm infant has less subcutaneous tissue, and therefore rests in a relaxed attitude.
The nurse is preparing to bathe a neonate born at 30 weeks gestation. Which practices by the nurse ensure the infant's safety? Select all that apply.
A
Gives the neonate a daily warm-water bath
B
Immerses the neonate fully (except the head) in the tub
C
Measures the body temperature within 2 to 4 hours before giving the bath
D
Uses cleansing agents with neutral pH and minimal dyes while giving the bath
E
Removes the vernix completely from the neonate's skin while giving the bath
The nurse is preparing to bathe a neonate born at 30 weeks gestation. Which practices by the nurse ensure the infant's safety? Select all that apply.
A
Gives the neonate a daily warm-water bath
CorrectB
Immerses the neonate fully (except the head) in the tub
CorrectC
Measures the body temperature within 2 to 4 hours before giving the bath
CorrectD
Uses cleansing agents with neutral pH and minimal dyes while giving the bath
IncorrectE
Removes the vernix completely from the neonate's skin while giving the bath
A neonate born before 32 weeks of gestational age is known as a preterm infant. Immersing the neonate's head in water during a bath can increase the risk of respiratory depression. The neonate's body temperature should be stable 2 to 4 hours before giving the initial bath. Therefore, the nurse monitors body temperature before giving a bath. Cleansing agents with neutral pH and minimal dyes reduce skin irritation, so these are used when bathing the neonate. The nurse should give a warm-water bath every second or third day, not daily, to prevent hypothermia. Removing vernix completely during the initial bath can alter thermoregulation in a neonate.
The primary health care provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is preterm and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation?
1
Administer intravenous fluids before applying emollient.
2
Avoid applying emollient to dry, flaking, and fissured areas of the skin.
3
Monitor for coagulase-negative staphylococcus infection.
4
Do not apply emollient and recheck with the primary health care provider.
The primary health care provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is preterm and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation?
1
Administer intravenous fluids before applying emollient.
2
Avoid applying emollient to dry, flaking, and fissured areas of the skin.
Correct3
Monitor for coagulase-negative staphylococcus infection.
Incorrect4
Do not apply emollient and recheck with the primary health care provider.
Emollients can cause coagulase-negative staphylococcus infection in a preterm infant who weighs less than or equal to 900 g. Intravenous fluids do not increase the effectiveness of emollients, so there is no need to administer intravenous fluids before applying the emollient. Emollients effectively reduce dry, flaking, and fissured areas on the infant's skin. Emollients are not contraindicated in preterm infants, so there is no need to avoid application or to recheck with the primary health care provider.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings?
1
The neonate has bleeding in the subgaleal layer during labor.
2
The neonate has cranial nerve V pressurized during labor.
3
The neonate has cranial nerve VII pressurized during labor.
4
Exposure to vaginal gonorrheal infection during labor.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings?
1
The neonate has bleeding in the subgaleal layer during labor.
Incorrect2
The neonate has cranial nerve V pressurized during labor.
Correct3
The neonate has cranial nerve VII pressurized during labor.
4
Exposure to vaginal gonorrheal infection during labor.
Inability to close the eyes completely, drooping of the corner of mouth, and absence of wrinkling of the forehead and nasolabial fold indicate facial paralysis. When the facial nerve, or cranial nerve VII, is pressurized during labor, it can result in facial paralysis. Bleeding in the subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal hemorrhage is not characterized by inability to close the eyes, drooping of the corner of mouth, or absence of wrinkling of the forehead and nasolabial fold. Cranial nerve V does not innervate the face, so damage to cranial nerve V does not result in facial paralysis. A neonate who is exposed to vaginal gonorrheal infections during labor may develop ophthalmia neonatorum, not facial paralysis.
One minute after birth a neonate's heart rate is 106 beats/min; acrocyanosis and muscle tone with flexion are observed; flicking the sole triggers crying; and the cry is strong. What is the neonate's Apgar score? Record your answer using a whole number.
4
The parents of a neonate born with a cleft lip ask a nurse when the cleft lip will be repaired. What is the best response by the nurse?
1
"When the baby has teeth."
2
"Sometime around 18 months of age."
3
"Usually before the baby is 12 weeks old."
4
"As soon as the baby starts to gain weight."
The parents of a neonate born with a cleft lip ask a nurse when the cleft lip will be repaired. What is the best response by the nurse?
1
"When the baby has teeth."
2
"Sometime around 18 months of age."
Correct3
"Usually before the baby is 12 weeks old."
Incorrect4
"As soon as the baby starts to gain weight."
Surgery is performed as soon as possible; if the infant is in good health, it may be done right after birth or by 6 to 12 weeks of age. Surgery is performed much earlier than 18 months; babies begin to have teeth at 7 to 8 months of age. Cleft palate, not cleft lip, may be repaired at this time. Healthy newborns lose weight during the first week of life. A decision to perform surgery at birth is not solely predicated on the newborn's weight gain or loss; other factors such as age are also considerations.
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
1
Encouraging more frequent breastfeeding during the first 2 days
2
Instituting phototherapy for 30 minutes every 6 hours for 3 days
3
Substituting formula feeding for breastfeeding on the second day
4
Supplementing breastfeeding with glucose water during the first day
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
Correct1
Encouraging more frequent breastfeeding during the first 2 days
Incorrect2
Instituting phototherapy for 30 minutes every 6 hours for 3 days
3
Substituting formula feeding for breastfeeding on the second day
4
Supplementing breastfeeding with glucose water during the first day
More frequent breastfeeding stimulates more frequent evacuation of meconium, thereby preventing resorption of bilirubin into the circulatory system. Phototherapy is the treatment for hyperbilirubinemia, and it is maintained continuously; it does not prevent the development of hyperbilirubinemia. It is not necessary to feed the infant formula. Early breastfeeding tends to keep the bilirubin level low by stimulating gastrointestinal activity. Increasing water intake does not limit the development of hyperbilirubinemia, because only small amounts of bilirubin are excreted by the kidneys.
A newborn's Apgar score at 5 minutes is 5. With what condition that requires intensive monitoring of this neonate does a low Apgar score 5 minutes after birth correlate?
1
Cerebral palsy
2
Genetic defects
3
Mental retardation
4
Neonatal morbidity
A newborn's Apgar score at 5 minutes is 5. With what condition that requires intensive monitoring of this neonate does a low Apgar score 5 minutes after birth correlate?
1
Cerebral palsy
Incorrect2
Genetic defects
3
Mental retardation
Correct4
Neonatal morbidity
Neonatal morbidity is related to neonatal morbidity and mortality; by 5 minutes the healthy neonate is relatively stable, with an Apgar score of 8 to 10, and requires routine care. The presence of cerebral palsy is not related to the Apgar score. It is rarely diagnosed in the newborn. Genetic defects may or may not be apparent at this time and are not related to the Apgar score. Mental retardation has not been proved to be correlated with Apgar score, although research continues in this area.
A nurse who is assessing a newborn 3 minutes after birth remembers that the heart rate of a healthy, alert neonate may range between:
1
120 and 180 beats/min
2
130 and 170 beats/min
3
110 and 160 beats/min
4
100 and 130 beats/min
A nurse who is assessing a newborn 3 minutes after birth remembers that the heart rate of a healthy, alert neonate may range between:
Incorrect1
120 and 180 beats/min
2
130 and 170 beats/min
Correct3
110 and 160 beats/min
4
100 and 130 beats/min
The newborn's heart rate varies with activity; crying can increase it to 180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110 beats/min constitutes bradycardia.
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect?
1
Tetany
2
Spina bifida
3
Hyperkalemia
4
Intracranial hemorrhage
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. What complication does the nurse suspect?
Incorrect1
Tetany
2
Spina bifida
3
Hyperkalemia
Correct4
Intracranial hemorrhage
Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement. Tetany is caused by hypocalcemia; it is manifested by exaggerated muscle twitching. Spina bifida is a defect of the spinal column that is observed at birth. An increased potassium level causes cardiac irregularities, not the irritable behavior observable with central nervous system involvement.
A nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication?
1
Persistent diarrhea
2
Decreased abdominal circumference
3
Small amount of vomitus after each gastric feeding
4
Increased amount of residual gastric volume from earlier feedings
A nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication?
1
Persistent diarrhea
2
Decreased abdominal circumference
Incorrect3
Small amount of vomitus after each gastric feeding
Correct4
Increased amount of residual gastric volume from earlier feedings
An increasing residual volume without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate because the cardiac (lower esophageal) sphincter of the stomach is weak.
A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?
1
Put a hat on the infant's head to avoid hypothermia.
2
Offer fluid every 15 minutes to prevent dehydration.
3
Keep the oxygen concentration consistent to limit respiratory distress.
4
Remove the infant from the hood every 15 minutes to provide stimulation.
A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?
Correct1
Put a hat on the infant's head to avoid hypothermia.
2
Offer fluid every 15 minutes to prevent dehydration.
Incorrect3
Keep the oxygen concentration consistent to limit respiratory distress.
4
Remove the infant from the hood every 15 minutes to provide stimulation.
Oxygen has a cooling effect, and the infant should be kept warm so metabolic activity and oxygen demands are not increased. Offering fluid every 15 minutes may produce fluid overload, which could in turn result in increased cardiac output; this is an undesirable outcome, especially for an infant with respiratory distress. Oxygen concentration is determined from blood gas levels and is changed accordingly. Removing the infant from the hood every 15 minutes will tire the infant and increase the need for oxygen.
After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?
1
Taking vital signs every hour
2
Keeping the eye shields on continuously
3
Administering additional fluids every 2 hours
4
Covering the neonate with a lightweight blanket
After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?
1
Taking vital signs every hour
Incorrect2
Keeping the eye shields on continuously
Correct3
Administering additional fluids every 2 hours
4
Covering the neonate with a lightweight blanket
Insensible and intestinal fluid losses are increased during phototherapy; extra fluid prevents dehydration. Taking the vital signs every hour is unnecessary unless a change from the baseline occurs. The eye shields should be removed for feeding and when the infant is being held. The total body needs to be exposed to the light.
An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What is the nurse's assessment of the neonate?
1
Small for gestational age (SGA) and term
2
SGA and preterm
3
Appropriate for gestational age (AGA) and term
4
AGA and preterm
An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What is the nurse's assessment of the neonate?
1
Small for gestational age (SGA) and term
2
SGA and preterm
Correct3
Appropriate for gestational age (AGA) and term
Incorrect4
AGA and preterm
Birth between 38 and 42 weeks' gestation is considered term; at term, healthy neonates weigh between 5 lb 10 oz and 8 lb 6 oz (2300 to 3800 g). Although the birth took place between 38 and 42 weeks' gestation (term infant), an SGA infant weighs less than the expected range for the gestational age. A preterm infant is one born before 38 weeks' gestation; the infant's weight is within the expected range for 40 weeks' gestation. Although the infant's weight is appropriate for the gestational age of 40 weeks, the infant is not preterm, because birth occurred between 38 and 42 weeks' gestation.
A nurse is caring for a neonate who is undergoing phototherapy. What specific care should the nurse plan for this infant?
1
Applying mineral oil to the skin to prevent excoriation
2
Covering the infant's head with a cap to minimize heat loss
3
Regulating radiant heat to maintain optimum skin temperature
4
Discontinuing therapy during feeding to meet the infant's emotional needs
A nurse is caring for a neonate who is undergoing phototherapy. What specific care should the nurse plan for this infant?
1
Applying mineral oil to the skin to prevent excoriation
Incorrect2
Covering the infant's head with a cap to minimize heat loss
3
Regulating radiant heat to maintain optimum skin temperature
Correct4
Discontinuing therapy during feeding to meet the infant's emotional needs
Discontinuing therapy during feedings is necessary to ensure psychosocial contact. Mineral oil may block light rays from acting on bilirubin deposits; cleansing after each voiding and defecation will prevent skin excoriation. All parts of the body may contain bilirubin deposits and should be exposed to the light. Radiant heaters are not used; a fluorescent light source is used.
A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?
1
20 to 40 breaths/min
2
30 to 60 breaths/min
3
60 to 80 breaths/min
4
70 to 90 breaths/min
A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?
Incorrect1
20 to 40 breaths/min
Correct2
30 to 60 breaths/min
3
60 to 80 breaths/min
4
70 to 90 breaths/min
After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.
A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?
1
Preterm
2
Immature
3
Small for gestational age
4
Appropriate for gestational age
A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?
Correct1
Preterm
Incorrect2
Immature
3
Small for gestational age
4
Appropriate for gestational age
Preterm describes a neonate born at 37 weeks' gestation or sooner, regardless of weight. There is no classification called immature. Small for gestational age means that the weight is below the 10th percentile at any week of gestation. Although this infant's weight is appropriate for gestational age, the term implies a healthy full-term infant.
A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply.
1
Pneumonia
2
Preterm birth
3
Microcephaly
4
Conjunctivitis
5
Congenital cataracts
A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply.
Correct1
Pneumonia
Correct2
Preterm birth
3
Microcephaly
Correct4
Conjunctivitis
Incorrect5
Congenital cataracts
Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy.
A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?
1

2

3

4

5
A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?

Correct2

A heart rate of less than 100 beats/min = 1; slow and irregular respirations = 1; grimaces in response to suctioning = 1; flaccid muscle tone = 0; and cyanosis = 0. This infant's Apgar score is 3. A score of 2 is too low. A score of 4 is too high, as is a score of 5.
While assessing a neonate the nurse observes ecchymotic-appearing areas on the buttocks and sacrum. The nurse concludes that this discoloration is probably related to the neonate's:
1
Skin color
2
Gestational age
3
Tendency to bleed
4
Vaginal breech birth
While assessing a neonate the nurse observes ecchymotic-appearing areas on the buttocks and sacrum. The nurse concludes that this discoloration is probably related to the neonate's:
Correct1
Skin color
2
Gestational age
3
Tendency to bleed
Incorrect4
Vaginal breech birth
These bluish discolorations are Mongolian spots, which are commonly found on the back and buttocks of dark-skinned newborns. These spots are unrelated to gestational age. Bluish spots on the buttocks are not areas of ecchymosis areas caused by bleeding. The buttocks and genitals of infants who are born vaginally in the breech presentation are usually edematous.
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented?
1
Stork bites
2
Forceps marks
3
Mongolian spots
4
Ecchymotic areas
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented?
Incorrect1
Stork bites
2
Forceps marks
Correct3
Mongolian spots
4
Ecchymotic areas
Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.
The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?
1
Cerebral palsy
2
Neonatal syphilis
3
Fetal alcohol syndrome
4
Opioid drug withdrawal
The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?
Incorrect1
Cerebral palsy
2
Neonatal syphilis
3
Fetal alcohol syndrome
Correct4
Opioid drug withdrawal
These signs are indicative of withdrawal from an opioid with typical changes occurring in the central nervous system; the newborn should be monitored during the first 24 to 48 hours. The signs of cerebral palsy usually manifest later in infancy. The signs of syphilis are a low-grade fever and a copious serosanguineous discharge from the nose. The signs of fetal alcohol syndrome are growth deficiencies in length, weight, and head circumference, plus distinctive facies.
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?
1
Stimulates the liver to dispose of the bilirubin
2
Breaks down the bilirubin into a conjugated form
3
Facilitates the excretion of bilirubin by activating vitamin K
4
Dissolves the bilirubin, allowing it to be excreted by the skin
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?
1
Stimulates the liver to dispose of the bilirubin
Correct2
Breaks down the bilirubin into a conjugated form
3
Facilitates the excretion of bilirubin by activating vitamin K
Incorrect4
Dissolves the bilirubin, allowing it to be excreted by the skin
Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.
After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed?
1
Monitoring of cardiac status
2
Assessment of neurological reflexes
3
Ensuring increased caloric intake and fluids
4
Administration of respiratory support and observation
After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed?
Incorrect1
Monitoring of cardiac status
2
Assessment of neurological reflexes
3
Ensuring increased caloric intake and fluids
Correct4
Administration of respiratory support and observation
The Silverman-Anderson score is an index of neonatal respiratory distress. A Silverman-Anderson score of 6 does not reflect cardiac function, neurological status, or caloric need.
As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence?
1
It is the precursor of newborn diarrhea.
2
It is a common finding in 2-day-old neonate.
3
It is a pathological condition of the digestive system.
4
It reflects immaturity of the autonomic nervous system.
As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence?
1
It is the precursor of newborn diarrhea.
Correct2
It is a common finding in 2-day-old neonate.
Incorrect3
It is a pathological condition of the digestive system.
4
It reflects immaturity of the autonomic nervous system.
Meconium is passed usually during the first several days of life, and it has no relationship to the pathological condition of diarrhea. Passage of meconium is desirable in the newborn because it indicates patency of the colon and a perforate anus. Although the newborn's autonomic nervous system is not fully developed at birth, gastrointestinal function is adequate to meet digestive, absorption, metabolic, and elimination needs.
When checking a newborn's reflexes, the nurse is unable to elicit one reflex response that is often absent in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response?
1
Moving the thumb along the sole of the foot
2
Stroking the ulnar surface of the hand and fifth finger lightly
3
Touching the skinfold of the mouth and cheek on the same side
4
Holding the infant in the upright position while pressing the feet flat on the crib mattress
When checking a newborn's reflexes, the nurse is unable to elicit one reflex response that is often absent in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response?
1
Moving the thumb along the sole of the foot
2
Stroking the ulnar surface of the hand and fifth finger lightly
Incorrect3
Touching the skinfold of the mouth and cheek on the same side
Correct4
Holding the infant in the upright position while pressing the feet flat on the crib mattress
Holding the infant in the upright position while pressing the feet flat on the crib mattress elicits the stepping response, which is absent when paresis is present and in neonates born vaginally in the breech presentation. Moving the thumb along the sole of the foot should elicit the Babinski reflex, which is unrelated to a vaginal breech birth. Stroking the ulnar surface of the hand and fifth finger lightly should elicit the digital response reflex, which is unrelated to a vaginal breech birth. Touching the skinfold of the mouth and cheek on the same side should elicit the rooting response reflex, which is unrelated to a vaginal breech birth.
A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause?
1
Neonatal sepsis
2
Rh incompatibility
3
Physiologic jaundice
4
ABO incompatibility
A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause?
1
Neonatal sepsis
2
Rh incompatibility
Incorrect3
Physiologic jaundice
Correct4
ABO incompatibility
There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause jaundice within the first 24 hours. The information provided does not indicate neonatal sepsis. Rh incompatibility is not a factor because the mother is Rh positive. Jaundice in the first 24 hours is not physiologic; it is pathologic.
The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information?
1
To determine whether there were previous fetal losses
2
To determine whether there are twins at home
3
To consider that someone recorded the gravida and para incorrectly
4
To consider that the current birth means that there were two pregnancies
The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information?
1
To determine whether there were previous fetal losses
2
To determine whether there are twins at home
Correct3
To consider that someone recorded the gravida and para incorrectly
Incorrect4
To consider that the current birth means that there were two pregnancies
Gravida refers to pregnancies, including this one, and para refers to pregnancies terminated (by whatever means) after the age of viability. If this is the client's only pregnancy (gravida 1) she could not have had a previous pregnancy that ended after the age of fetal viability. Para will not exceed gravida. One pregnancy is gravida 1. A twin pregnancy is still one pregnancy terminated after the age of viability. Because the documentation of the client indicates that she is gravida 1, it cannot be assumed that it is the woman's second pregnancy.
The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply.
1
Hypotonia
2
Polydactyly
3
Umbilical hernia
4
Hypoplastic maxilla
5
Small, upturned nose
The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply.
Correct1
Hypotonia
2
Polydactyly
Incorrect3
Umbilical hernia
Correct4
Hypoplastic maxilla
Correct5
Small, upturned nose
Hypotonia is associated with FAS, as well as with Down syndrome. A receding chin (hypoplastic maxilla) is associated with FAS. The typical facies associated with FAS also usually includes a small, upturned nose, which is distinctive in these infants. Polydactyly (extra fingers) is associated with the trisomies. An umbilical hernia can develop in early infancy and is not related to FAS.
Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply.
1
Tremors
2
Dehydration
3
Hyperactivity
4
Muscle hypotonicity
5
Prolonged sleep periods
Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply.
Correct1
Tremors
Incorrect2
Dehydration
Correct3
Hyperactivity
4
Muscle hypotonicity
Incorrect5
Prolonged sleep periods
Opioid dependence in the newborn is physiological; as the drug is cleared from the body, signs of drug withdrawal become evident. Tremors are a typical sign of cerebral irritability. Hyperactivity is a typical sign of cerebral irritability. Dehydration is a result of inadequate feeding, not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid withdrawal. Signs of opioid withdrawal include excessive activity and sleep disturbances.
A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply.
1
Isomil
2
Phenex
3
Enfamil
4
Prosobee
5
Lofenalac
A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply.
Incorrect1
Isomil
Correct2
Phenex
Incorrect3
Enfamil
4
Prosobee
Correct5
Lofenalac
Phenex is a milk substitute that contains casein hydrolysate, which provides 0.4% phenylalanine. The infant's blood level of phenylalanine must be kept below 8 mg/dL to prevent protein catabolism; however, the blood level must remain above 2 mg/dL to promote growth and development. Lofenalac is a milk substitute that contains only 0.4% phenylalanine; it is a safe milk substitute for an infant with PKU. Isomil, Enfamil, and Prosobee all contain more than the recommended amount of protein.
An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. What is the nurse's estimate of the infant's age?
1
2 days

2
24 hours

3
About 3 to 4 days

4
Less than 24 hours
An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. What is the nurse's estimate of the infant's age?
1
2 days
Incorrect2
24 hours
Correct3
About 3 to 4 days
4
Less than 24 hours
Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and provides evidence that the mother may have had gonorrhea or a chlamydial infection. The most common presentation of ophthalmia neonatorum occurs by day 3 after birth.
A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of infection control precautions should the nurse institute?
1
Enteric
2
Contact
3
Droplet
4
Standard
A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of infection control precautions should the nurse institute?
1
Enteric
2
Contact
Correct3
Droplet
Incorrect4
Standard
Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet transmitted infection.
The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?
1
Most important is diagnosis within 2 days after birth.
2
Most important is the institution of a corrective formula soon after birth.
3
It depends on whether phenylpyruvic acid is found in the urine 1 week after birth.
4
It depends on the level of phenylalanine found in the blood immediately after birth.
The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?
1
Most important is diagnosis within 2 days after birth.
Correct2
Most important is the institution of a corrective formula soon after birth.
3
It depends on whether phenylpyruvic acid is found in the urine 1 week after birth.
Incorrect4
It depends on the level of phenylalanine found in the blood immediately after birth.
Adherence to a diet low in phenylalanine is necessary for optimal physical growth and little or no adverse effect on mental development; a restricted diet that is instituted late will not reverse brain damage. Detection cannot occur until the infant has taken milk or formula that contains phenylalanine for 24 hours and metabolites have accumulated in the blood; behaviors indicating mental retardation and central nervous system involvement are usually evident by about 6 months of age in the untreated infant. Phenylpyruvic acid in the urine is an intermediate product of the metabolism of phenylalanine in the body. It is related to compliance with the prescribed diet after the diagnosis is made. There is no phenylalanine in the blood at birth; it first becomes measurable after the infant ingests milk or formula.
An adolescent gives birth to an infant with a severe cleft palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate?
1
"Oh no! This is the wrong baby!"
2
"I'm so sad. Do you think I'm being punished?"
3
"My parents will be so upset. What could have happened?"
4
"I shouldn't have had this baby! Now my boyfriend won't marry me."
An adolescent gives birth to an infant with a severe cleft palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate?
Correct1
"Oh no! This is the wrong baby!"
Incorrect2
"I'm so sad. Do you think I'm being punished?"
3
"My parents will be so upset. What could have happened?"
4
"I shouldn't have had this baby! Now my boyfriend won't marry me."
Denial or disbelief and shock are considered initial grieving responses. There is a feeling of guilt and inadequacy when an infant is born with a defect. It is unusual for a client to initially verbalize feelings of punishment or guilt so directly. A sense of shame and guilt is voiced later, after denial, disbelief, and shock have occurred. It is unusual for a client to use rationalization and voice it so obviously.
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.
1
Irritability
2
High-pitched cry
3
Depressed fontanels
4
Decreased urinary output
5
Ineffective feeding behavior
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.
Correct1
Irritability
Correct2
High-pitched cry
3
Depressed fontanels
4
Decreased urinary output
Correct5
Ineffective feeding behavior
Pressure on the cerebral structures influences the central nervous system, resulting in irritability. A high-pitched cry is common in neonates with increased ICP. Ineffective feeding behavior is typical of neonates with increased ICP. The fontanels are bulging, not depressed, with increased ICP. Decreased urinary output is related to dehydration and kidney problems, not increased ICP.
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.
1
Thin upper lip
2
Wide-open eyes
3
Small upturned nose
4
Larger-than-average head
5
Smooth vertical ridge in the upper lip
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.
Correct1
Thin upper lip
2
Wide-open eyes
Correct3
Small upturned nose
4
Larger-than-average head
Correct5
Smooth vertical ridge in the upper lip
The abnormal facies associated with FAS includes a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.
A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority.

1.
Apply identification band to mother and infant.

2.
Perform physical assessment.

3.
Place skin to skin.

4.
Instill antibiotic prophylaxis and administer vitamin K.
A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority.
Incorrect
1.
Apply identification band to mother and infant.
Incorrect
2.
Perform physical assessment.
Incorrect
3.
Place skin to skin.
Correct
4.
Instill antibiotic prophylaxis and administer vitamin K.
Hypothermia can cause many complications for a newborn, and therefore it should be avoided by initiating skin-to-skin contact Placing the identification band on the mother and infant is a safety measure that should be performed after thermoregulation needs are met. A physical assessment should be performed next to identify any additional nursing interventions that may be needed in light of physical assessment findings. Instillation of the antibiotic and administration of vitamin K should be completed within an hour of birth or per facility policy.
A nurse has inserted a nasogastric tube to gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage.

1.
Clamp the tube.

2.
Connect the barrel of a syringe to the gavage tube.

3.
Pour the prescribed amount of formula into the syringe.

4.
Allow the feeding to flow at a rate of 1 mL/min.

5.
Place the infant on the right side.
A nurse has inserted a nasogastric tube to gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage.
Incorrect
1.
Clamp the tube.
Incorrect
2.
Connect the barrel of a syringe to the gavage tube.
Correct
3.
Pour the prescribed amount of formula into the syringe.
Correct
4.
Allow the feeding to flow at a rate of 1 mL/min.
Correct
5.
Place the infant on the right side.
The first step is to connect the tubing to a syringe; the formula should not be poured directly into the tubing. The tube must be crimped before the formula is poured into the syringe so the flow rate may be controlled while the formula is being released from the syringe. After the tube is crimped, the formula should be poured into the syringe to ensure that the infant will receive the specified amount. Once the formula is in the syringe, the crimp is released and the rate of flow controlled. A rate of 1 mL/min is best tolerated. After the feeding has been completed, the infant should be turned on the right side to prevent aspiration. During the feeding, the infant may be held.
When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?
1
They are common and will disappear in 2 to 3 days.
2
They are birthmarks that will disappear in 3 to 4 months.
3
Avoid squeezing them and don't try to wash them off.
4
Proper handwashing technique is important because milia are infectious.
When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?
Incorrect1
They are common and will disappear in 2 to 3 days.
2
They are birthmarks that will disappear in 3 to 4 months.
Correct3
Avoid squeezing them and don't try to wash them off.
4
Proper handwashing technique is important because milia are infectious.
Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. The white material is not purulent and is not infectious.
A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.
1
Weight
2
Length
3
Breast size
4
Tonic-neck reflex
5
Genital development
A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.
Incorrect1
Weight
Incorrect2
Length
Correct3
Breast size
4
Tonic-neck reflex
Correct5
Genital development
The presence of breast buds and the development of breast tissue occur at a specific time during gestation and are reliable indicators of gestational age, as is the development of genitalia, which also occurs at a specific time during gestation. Weight and length, which are influenced by both genetics and prenatal stresses, are not accurate indicators of gestational age. The tonic-neck reflex is a primitive reflex found in newborns that disappears at 6 months, but it is not a component of the gestational age assessment.
A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?
1
Supporting the parents
2
Recording neurologic signs
3
Protecting the infant's head
4
Applying ice packs to the hematoma
A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?
Correct1
Supporting the parents
2
Recording neurologic signs
Incorrect3
Protecting the infant's head
4
Applying ice packs to the hematoma
Parents need support and reassurance that their newborn is not permanently damaged. Cephalohematomas do not cause impaired neurologic function. No special protection of the head is required; routine safety measures are adequate. Cephalohematomas resolve spontaneously; ice is not applied.
Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?
1
Microcephaly
2
Narrow chest
3
Enlarged head
4
Expected head size
Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?
1
Microcephaly
2
Narrow chest
Correct3
Enlarged head
Incorrect4
Expected head size
The enlarged head may indicate hydrocephalus. Average head circumference in the healthy newborn is 13.2 to 14 inches (33 to 35 cm), about 1 inch (2.5 cm) larger than the chest circumference. Microcephaly indicates that the head is smaller than expected, not larger. The chest circumference of 13 inches (32.5 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large.
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?
1
Cardiac defect
2
Kidney disorder
3
Diabetes mellitus
4
Esophageal atresia
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?
Incorrect1
Cardiac defect
2
Kidney disorder
3
Diabetes mellitus
Correct4
Esophageal atresia
Esophageal atresia is associated with hydramnios. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.
A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.
1
Sneezing
2
Hyperactivity
3
High-pitched cry
4
Exaggerated Moro reflex
5
Reduced deep tendon reflexes
A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.
Correct1
Sneezing
Correct2
Hyperactivity
Correct3
High-pitched cry
Incorrect4
Exaggerated Moro reflex
5
Reduced deep tendon reflexes
Neurological signs of withdrawal in a neonate of an opioid-addicted mother are manifested by sneezing. Other signs exhibited by neonates undergoing withdrawal are hyperactivity and jitteriness and a shrill, high-pitched cry. The Moro reflex usually becomes weaker as the signs of withdrawal become apparent. The deep tendon reflexes are exaggerated during opioid withdrawal.
A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge that infants who are fed with ready-to-use formula do require a supplement. What supplement is required?
1
Iron
2
Fluoride
3
Vitamin K
4
Vitamin B12
A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge that infants who are fed with ready-to-use formula do require a supplement. What supplement is required?
Incorrect1
Iron
Correct2
Fluoride
3
Vitamin K
4
Vitamin B12
Unless fluoridated water is used by the manufacturer, fluoride supplementation of 0.25 mg daily is required. Commercial formulas are fortified with iron. The supply of vitamin K is adequate after the first week of life. Supplemental vitamin B12 is unnecessary; it may be needed if the mother is a vegetarian and is breastfeeding.
As a client who has just given birth examines her newborn, she notes a nevus vasculosus on her infant's mid thigh and becomes upset. How should the nurse respond?
1
"These areas usually spread and then regress."
2
"The mark is superficial and will fade in a few days."
3
"The mark is permanent, but it can be covered with clothes."
4
"The area may require surgical removal when your baby is a little older."
As a client who has just given birth examines her newborn, she notes a nevus vasculosus on her infant's mid thigh and becomes upset. How should the nurse respond?
Correct1
"These areas usually spread and then regress."
Incorrect2
"The mark is superficial and will fade in a few days."
3
"The mark is permanent, but it can be covered with clothes."
4
"The area may require surgical removal when your baby is a little older."
Spreading and then regressing is the usual pattern that a nevus vasculosus, which involves the dermal and subdermal layers, follows. Saying that the area will be covered by clothes gives little assurance. Surgical removal is not recommended.
The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?
1
Heel stick
2
Buccal smear
3
Urinary catheterization
4
Venous blood withdrawal
The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?
Incorrect1
Heel stick
Correct2
Buccal smear
3
Urinary catheterization
4
Venous blood withdrawal
The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine is not used to assess chromosomal aberrations; neither is venous blood.
A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.
1
Crackles
2
Cyanosis
3
Wheezing
4
Tachypnea
5
Retractions
A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.
1
Crackles
Correct2
Cyanosis
Incorrect3
Wheezing
Correct4
Tachypnea
Correct5
Retractions
Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.
A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?
1
Gastric acidity is low and does not provide bacteriostatic protection.
2
Absence of hydrochloric acid renders the stomach vulnerable to infection.
3
Infants are almost completely lacking in immunity and require sterile fluids.
4
Escherichia coli, a bacterium that is found in the stomach, does not act on milk.
A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?
Correct1
Gastric acidity is low and does not provide bacteriostatic protection.
Incorrect2
Absence of hydrochloric acid renders the stomach vulnerable to infection.
3
Infants are almost completely lacking in immunity and require sterile fluids.
4
Escherichia coli, a bacterium that is found in the stomach, does not act on milk.
Low gastric acidity in newborns predisposes them to gastrointestinal infections, so it is necessary to clean bottles with soap and water. Hydrochloric acid is present in the gastric juices but not in quantities sufficient to protect the infant. The infant is born with passive immunity from maternal antibodies. Escherichia coli is an intestinal bacterium; it is not found in the stomach.
After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply.
1
Profuse scalp hair
2
Parchmentlike skin
3
Abundant vernix caseosa
4
Few rugae over the scrotum
5
Creases covering the entire soles
After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply.
Correct1
Profuse scalp hair
Correct2
Parchmentlike skin
3
Abundant vernix caseosa
4
Few rugae over the scrotum
Correct5
Creases covering the entire soles
Profuse scalp hair is associated with a postterm newborn. As the fetus matures, usually the hair on the scalp becomes more profuse. Parchmentlike skin is associated with a postterm newborn. Skin desquamation occurs as a result of prolonged exposure to amniotic fluid, causing cracking, peeling, and drying of skin and resulting in a parchmentlike appearance. Creases will cover the entire sole of each foot if the newborn is full term or postterm; preterm newborns have an absence of or few skin creases on the soles of the feet. Abundant vernix caseosa is associated with a preterm newborn. Postterm newborns exhibit little vernix caseosa. Immature genitals (e.g., undescended testes, small scrotum, few rugae over the scrotum) are associated with a preterm newborn. As the fetus reaches full term and beyond, both testes usually descend and rugae cover the scrotal sac.
Which newborn assessment finding will probably necessitate prolonged follow-up care?
1
Apgar score of 5
2
Weight of 3500 g
3
Blood glucose level of 50 mg/dL
4
Umbilical cord with two blood vessels
Which newborn assessment finding will probably necessitate prolonged follow-up care?
Incorrect1
Apgar score of 5
2
Weight of 3500 g
3
Blood glucose level of 50 mg/dL
Correct4
Umbilical cord with two blood vessels
The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. It is too soon to determine whether the newborn needs prolonged follow-up care; this conclusion is based on the second Apgar score, 5 minutes later. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL.
The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?
1
They are obstructed sebaceous glands.
2
They are excessive superficial capillaries.
3
The cause is a decreased vitamin K level in the newborn.
4
The cause is an increased intravascular pressure during birth.
The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?
1
They are obstructed sebaceous glands.
Incorrect2
They are excessive superficial capillaries.
3
The cause is a decreased vitamin K level in the newborn.
Correct4
The cause is an increased intravascular pressure during birth.
Pressure exerted during the birth process causes increased intravascular pressure, which may result in petechiae caused by capillary rupture. Obstructed sebaceous glands are milia, which are white, not red. Superficial capillaries are intact capillaries. They are distinguished from petechiae if they disappear when the area is blanched. Bloody stools or oozing from the umbilicus is the most common sign of vitamin K deficiency, not red pinpoint dots on an infant's face and neck.
Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?
1
3

2
4

3
5

4
6
Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?
1
3
2
4
Correct3
5
Incorrect4
6
According to the Apgar scoring system, the newborn receives 2 points for heart rate, 0 for color, 1 for respiratory effort, 1 for muscle tone, and 1 for reflex irritability. An Apgar score of 3 is low. Scores of 5 and 6 are higher, but the newborn may still require stimulation and oxygen.
A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply.
1
Preterm infant
2
Infant with Down syndrome
3
Small-for-gestational-age infant
4
Large-for-gestational-age infant
5
Appropriate-for-gestational-age infant
A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply.
Correct1
Preterm infant
Incorrect2
Infant with Down syndrome
Correct3
Small-for-gestational-age infant
Correct4
Large-for-gestational-age infant
5
Appropriate-for-gestational-age infant
Preterm infants have low glycogen stores. Small-for-gestational-age infants have low glycogen stores. Large-for-gestational-age infants are prone to hyperinsulinemia; often they are born to mothers who have diabetes, meaning that they are exposed to a high circulating glucose level while in utero. After prolonged exposure to a high glucose level, hyperplasia of the pancreas occurs, resulting in hyperinsulinemia. Infants with Down syndrome are not at risk for hypoglycemia but are at risk for congenital cardiac defects. Appropriate-for-gestational-age infants are not at risk for hypoglycemia.
A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply.
1
Hypotonia
2
Webbed neck
3
Female sex organs
4
Rocker-bottom feet
5
Widely spaced nipples
A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply.
1
Hypotonia
Correct2
Webbed neck
Correct3
Female sex organs
4
Rocker-bottom feet
Correct5
Widely spaced nipples
The broad, webbed neck is an outstanding characteristic of the newborn with Turner syndrome. All infants with Turner syndrome are female because their one sex chromosome is the X chromosome; although they have female sex organs, the organs are underdeveloped and affected individuals are infertile. Widely spaced nipples are also a characteristic of Turner syndrome. Hypotonia is typical of newborns with Down syndrome and trisomy18. Rocker-bottom feet are found in infants with trisomy 18.
A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.
1
Fever
2
Seizures
3
Deafness
4
Conjunctivitis
5
Cardiac anomalies
A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.
Incorrect1
Fever
2
Seizures
Correct3
Deafness
4
Conjunctivitis
Correct5
Cardiac anomalies
Depending on the specific period of organogenesis when the mother contracted rubella, a variety of defects may occur. Deafness is a typical sign of a newborn affected by a mother who had rubella during early pregnancy. Cardiac anomalies are common in newborns if the mother had rubella during pregnancy during the time of organogenesis. Fever is expected if the mother had an active herpes simplex virus infection or toxoplasmosis at the time of a vaginal birth. Central nervous system problems occur when the mother had toxoplasmosis or an active herpes simplex infection during pregnancy. Conjunctivitis is found in newborns whose mothers had gonorrhea or Chlamydia during a vaginal birth.
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