Davis Edge Chapter 15: Nursing Care of Neonate & Family

The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complication? Select all that apply.

Meconium-stained amniotic fluid

Labor and birth after 40 weeks' gestation

Maternal hypertension

Maternal age of 18

Prolonged labor over 24 hours

1, 3, and 5

Rationale:

1. This may cause respiratory distress in the newborn.

3. This may affect uteroplacental oxygenation

5. This may add stress to the fetus and deplete oxygen reserves.

When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply.

Mongolian spots

Instant ear recoil

Testis in the scrotum

Acrocyanosis

00 square window

2, 3, and 5

Rationale:

2. Term neonates will have instant ear recoil.

3. Testis will be descended with good rugae

5. Term neonates have no angle when performing the square window of the wrist.

The nurse is performing screening and laboratory tests on an infant 24 hours after delivery. Select the finding from the following options that should be reported to the neonatal provider.

Milia

Caput on occiput

Hemangioma on left forearm

Critical congenital screen heart defect screening results

Lethargy

4 and 5

Rationale:

4. The preductal and postductal screens show a greater than 3% difference between the readings. This is a concern for possible cardiac abnormalities with the infant.

5. Neonates will be difficult to arouse and feed.

A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate?

Rub the back to stimulate crying.

Administer oxygen per protocol.

Suction the mouth and nose with a bulb syringe.

Notify the provider and begin CPR.

3.

Rationale: This is the priority if the airway needs to be cleared of secretions.

The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply.

Clean the penis every diaper change and wrap with petroleum-impregnated gauze.

Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy.

Assess for urination and document findings.

Administer pain medication if ordered.

Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

2, 3, and 4

Rationale:

2. Frequency of assessment should be at least every 15 minutes for the first hour and follow hospital policy for reassessments.

3. Assessing for urination is necessary to ensure no trauma occurred during the procedure.

4. Admin med if ordered.

A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse?

"This can be caused by blood in the stool; I will check it to make sure everything is okay."

"Let me call the physician and see if we need to supplement the baby with formula."

"The stool is normal and called meconium. The baby may pass this for the first day or two."

"The iron you took during the pregnancy caused the stool to be tarry and thick."

3.

Rationale: This is meconium stool.

A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician?

Bluish discolorations on the buttocks area

Yellow coloring of the skin

Small amount of regurgitation with feedings

Meconium passage with every bowel movement

2.

Rationale: Jaundice in the first 24 hours of birth is an abnormal finding.

A nurse is evaluating the reflexes in a large-for-gestational-age (LGA) infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse?

Notify the provider.

Reassess using a different technique.

Document the findings.

Reassess after the infant is 24 hours old.

1.

Rationale: The infant may have a nerve injury and needs to be evaluated because of the asymmetrical response.

The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate?

Preterm infants have less brown fat stores at birth to use for thermoregulation.

Preterm infants have well-developed flexor muscles to be able to shiver when cold stressed.

The term infant is more prone to dehydration than the preterm infant.

Preterm infants have abundant lanugo to use for thermoregulation.

1.

Rationale: Preterm infants have less brown adipose tissue (brown fat) than term infants.

A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems?

Neonates have a smaller body surface area.

Neonates have limited subcutaneous fat.

Neonates are able to shiver and increase heat production.

Neonates have a lower metabolic rate.

2.

Rationale: Neonates have a limited subcutaneous fat and a high metabolic rate. They also have limited thermoregulatory abilities.

The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation?

Irregular breathing pattern

32 breaths per minute

Retractions of chest wall

Diaphragmatic and abdominal breathing

3.

Rationale: Considered and abnormal finding

A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse?

"She may lose weight until your milk comes in."

"It is normal for the baby to lose 5% to 10% of her weight during the first week due to diuresis."

"The baby may be dehydrated, which is not uncommon in a breastfed baby."

"The baby is having bowel movements, which results in a weight change."

2.

Rationale: As a renal system begins to balance fluid and electrolytes, urinary output increases.

The nurse performs an assessment on a 34-week neonate born 4 hours ago. Which assessment finding would be indicative of a preterm neonate?

Acrocyanosis

Abundant lanugo

Hypertonia

Tachycardia

2.

Rationale: often seen in preterm neonates.

A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss?

Low-set ears

Absent startle reflex

Ear pits or tags

Failed hearing screen

2.

Rationale: associated with possible hearing loss.

The nurse places the newborn on the mother skin-to-skin immediately after birth. What is the most appropriate teaching for the mother at this time?

Encourage the mother to initiate breastfeeding and provide support.

Provide education for the hepatitis B vaccine before administration.

Teach the importance of bonding and rooming-in.

Discuss the methods of heat loss and provide examples.

1.

Rationale: During the initial period of reactivity, the mother should be encouraged to initiate breastfeeding.

The nurse is assigned four couplets. After assessing each, which newborn should the nurse report to the physician?

A 23-hour-old neonate who has not passed meconium

A 6-hour-old neonate who is large for gestational age (LGA) with a glucose of 41

A 2-day-old neonate who has a blood-tinged vaginal discharge

A 2-day-old neonate with irregular respirations at 70 per minute

4.

Rationale: The normal respiratory rate is 30 to 60. Tachypnea when neonate is not crying or active is a concern.

The nurse is admitting a neonate who was delivered vaginally via vacuum extraction and notes a dark red area of unilateral swelling on the scalp. What is the priority nursing action?

Notify the physician.

Obtain an order for a bilirubin.

Document the findings.

Check the neonate's head circumference.

3.

Rationale: There is no intervention for the finding of a cephalohematoma.

A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions that follow in the correct order.

Obtain Apgar scores.

Dry the neonate.

Assess vital signs.

Place the neonate skin-to-skin.

2, 4, 1, 3

Rationale: The neonate should be dried first to prevent evaporative heat loss and placed on the mother for bonding and thermoregulation. The APGAR scores can be obtained while skin-to-skin. If stable, vital signs can be obtained within the first 30 minutes after birth.