ch 12,13,14 Flashcards
1
Q
Newborn Reflexes
A
Newborns can move their arms and legs vigorously but CANNOT control them.
Newborn cannot maintain neutral position of the head.
The reflexes of a full term is blinding, sneezing, gagging,sucking,grasping, they can cry, swallow, and lift their head on their abdomen.
2
Q
Preventing Infection in the Newborn
A
standard precautions, handwashing, cleansing,and replacement of equipment and proper disposal of soiled diapers and linens. HANDWASHING is the most reliable precaution.
3
Q
Care of the male after circumcision
A
Keep area clean, change diaper, wash area with warm water,avoid alcohol- containing wipes, do not remove yellow crusts from penis. apply diaper loosely to prevent inf. report redness and bleeding or drainage. observe for atleast 6 wet diapers qd.
4
Q
Occurrences in each body system for a newborn
A
Respirations are stimulated by chilling and by chemical changes within the blood. Sensory and physical stimuli appear to play a role in resp. function. The first breath opens the alveoli. This process also initiates cardiopulmonary interdependence. The newborns ability to metabolize is hendered by the immaturity of digestive system bc of deficencies of enzymes from pancreas and liver.
5
Q
Occurrences in each body system for a newborn
A
The kidneys are structurally developed but their abiiity to concentrate urine and maintain fluid balance is limited bc of a decreased rate of glomerular flow and limited renal tubular reabsorption. Most neurological functions are primitive.
6
Q
signs and sx of respiratory distress
A
rate and character of respirations, color (cyanosis), and general behavior. Sternal retractions are reported immediately. Nasal flaring, chest retraction
7
Q
normal range for temperature
A
- 6-37.2C
97. 8-98.9F
8
Q
normal range for pulse rate
A
110-160 bpm irregular and rapid.
9
Q
normal BP
A
80/46 mm Hg
10
Q
normal RR
A
30-60 breaths/min
11
Q
proper use on the bulb syringe
purpose: to clear airway of mucus.
A
- Compress the ball of the bulb syringe.
- insert the narrow portion of the bulb into the side of the mouth to avoid stimulating the gag reflex. Suction mouth first to prevent inhalation and aspiration of mucus during a gasp reflex. which is stimulated by nasal suctioning.
- Release the pressure on the ball of the bulb and listen for the sound of mucus being suctioned.
- remove bulb and empty contents into a receptacle by compressing the bulb
- compress the bulb and insert into one nostril then release pressure on the bulb to suction mucus out.
12
Q
Routine discharge instructions for the newborn
A
Basic care of the infant, including bath, cord care, circumcision care, feeding, and elimination.
safety measures, including position for sleep.
immunizations
support groups, such as La Leche League.
Return appts for well-baby care.
telephone number of the nursery (24 hr availibility)
proper use of car seats
signs and symptoms of probs and whom to contact, a temp greater than 100.4 (38C) by axilla, refuse two feedings in a row, two green watery stools, frequent or forceful vomiting, lack of voiding or stooling.
13
Q
tonic neck reflex
A
a postural reflex that is sometimes assumed by sleeping infants. the head is turned to one side and rhe arm and leg are extended on the same side. the opposite arm and leg are flexed in a fencing position.
14
Q
dancing or stepping reflex.
A
prancing movements of the legs seen when a infant is help upright on the examining table.
15
Q
molding
A
the conforming of the fetal head to the size and shape of the birth canal
16
Q
caput seccedaneum
A
swelling of the soft tissues of the scalp, subsides without tx.
17
Q
cephalohematoma
A
“head,blood,tumor” protrudes from beneath the scalp and is caused from a collection of blood beneath the periosteum of the cranial bone- dont cross the suture line. recedes in a few weeks without tx.
18
Q
fontanelles
A
are unossified spaces or soft spots on the cranium of the young infant. they protect the head during delivery by permitting the process of molding and further brain growth during the next 1 1/2 yr
19
Q
the anterior fontanelle
A
diamond shaped and is located in the junction of two parietal and two frontal bones- closes by age 12-18 mo
20
Q
the posterior fontanelle.
A
triangular and is located between the occipital and parietal bones- smaller than anterior fontanelle usually ossified byend second mo.
21
Q
lanugo
A
the body is usually covered with white fine hair- disappears first week of life.
22
Q
Vernix Caseosa
A
a cheeselike substance that covers the skin of the newborn and is made up of cells and glandular secretions- protects skin from irritation and effects of a water enviorment in utero.
23
Q
milia
A
white pin point “pimples” caused by the obstruction of sebaceous glands may be seen on nose and chin. they disappear within a few weeks
24
Q
Epsteins pearls
A
Milia type lesions on the midline of the hard palate and are caused by a collection of epithelial cells.
25
Mongolian spots
bluish discolorations of the skin, common with infants of african american, native american, and mediterranean.
26
Acrocyanosis
or peripheral blueness of the hands and feet and is normal and results from poor peripheral circulation.
27
Icterus neonatorum
physiological jaundice- characterized by a yellow tinge of the skin. caused by rapid destruction of excess red blood cells which isnt needed anymore bc theyre in a atmosphere that has more o2
28
meconium
the first stool, a mix of amniotic fluid and secretions if the intestinal glands- dark greenish black thick and sticky (tarry) and is passed 8-24 hr after birth
29
premature and low birth weight are often concomitant and both factors are associated with increased neonatal mortality. the less the infant weighs at birth the greater the risks to life during delivery and immediately thereafter
know
30
gestational age
refers to the actual time, from conception to birth that the fetus remains in the uterus
31
preterm infant
less than 37 weeks
32
early term infant
born between 37 weeks and 38 weeks and 6 days
33
full term infant
one born between 39 and 40 weeks and 6 days
34
late term infant
one born between 41 weeks and 41 weeks and 6 days
35
postterm infant
born beyond 42 weeks
36
ballard scoring system
a standardized method used to estimate gestational age within 1-2 weeks- based on infants external characteristics and neuro development. the estimated gestational age is determined by the mothers last normal period and US evaluation all are methods
37
previability
before life capable of" the muscles that move the chest are not fully developed, abdomen is distended, creating pressure on the diaphragm; the simulation of respiratory center in the brain is immature; the gag and cough reflexes are weak bc of immature nerve supply
38
respiratory distress syndrome RDS
also called hyaline membrane disease
RDS type 1 is lung immaturity, reduced gas exchange.
30% of deaths from RDS
39
surfactant
a chemical in the lungs. high in lecithin, a fatty protein necessary for the absorption of 02 in lungs
40
bronchopulmonary dysphasia
is the toxic response of the lung to oxygen therapy. atelectasis, edema, and thickening of the membranes of the lung interfere with ventilation.
41
apnea
defined as the cessation of breathing for 20 seconds or longer. not uncommon for preterm newborn and is believed to be related to the immaturity of the nervous system.
42
bradycardia
an apneic episode may accompany a HR lower than 110 BPM and cyanosis- gentle rubbing of infants feet, ankles and back may stimulate breathing.
43
hypoxia
is an inadequate oxygenation at cellular level in a newborn infant.
44
pulse oximetry
defined as a measure of oxygen on the hgb in the circulating blood divided by the oxygen compacity of the hbg. 92% and higher is normal.
45
sepsis
a generalized inf of the blood. preterms are at risk for this as many systems are not mature. the liver of a preterm is immature and forms antibodies poorly. body enzymes are inefficent bc ot the abbreviated stay in the uterus.
46
hypoglycemia
low sugar in blood. common with preterm infant. they have not been in uterus long enough to acquire sufficent stores of glycogen and fat
47
hypocalcemia
low calcium in the blood. seen in preterm and sick newborns
48
retinopathy of prematurity ROP
is a disorder of the developing retina in premature infants that can lead to blindness. leading cause of blindness in infants weighing less than 3.3lb
49
Necrotizing enterocolittis NEC
an acute inflammation of the bowel that leads to bowel necrosis- factors include a diminished blood supply to the lining of the bowel wall bc of hypoxia or sepsis.
50
icterus
jaundice; the liver of the newborn is immature- causes the skin and white of the eyes to assume a yellow-orange cast
51
importance of thermoregulation
involves maintaining a stable body temp and preventing hypothermia (low temp) and hyperthermia (high temp) a stable body temp is essential to survival and management of preterm
52
symptoms of cold stress
decreased temp, pallor, lethargy
53
feeding of the preterm newborn varies with gestational age and health status. a preterm infant may require gavage feedings (via a tube placed through mouth or nose into the stomach) infants weighing 3.3lb can be bottle fed if a soft nipple with a large hole is used to minimize energy end effort..
if the infant is gavage fed the tube is replaced every 3-7 days. IV fluids may be provided to meet fluid, calories,and electrolyte needs in small, weak, preterm infants. often theyre fed while still in incubator.
when gavage fed the contents of the stomach should be aspirated b4 feeding is started. if only mucus or air is aspirated continue with feeding as planned.
54
formula for a term infant is usually not tolerated well by preterm infants bc they are burden to their kidneys and can cause CNS probs. formulas designed for preterm infants are not tolerated by older infants 34 weeks and up
or term infants bc hypercalcemia may develop.
55
total parenteral nutrition
IV infusions of lipids and nutrients may be prescribed to meet the infants nutritional and growth needs.
56
Increased tendency to bleed
preterm infants are more prone to bleeding than full term bc their blood is deficicent in prothrombin, a clotting factor mechanism. Fragile capillaries of the head are suceptible to injury during delivery causing intercranial hemorrhage, look for bulging fontanelles,lethargy, poor feeding, and seizures. the bed should be in slight fowlers and unecessary stimulation can cause intercerebral pressure avoided.
57
problems of the post term newborn
beyond 42 wks) Asphyxia-caused by chronic hypoxia while in the uterus bc of a deteriorated placenta.
Meconium aspiration:hypoxiaand distress may cause relaxation of the anal sphincter and meconium can be aspirated into lungs
poor nutritional status: depleted glycogen reserves cause of hypoglycemia.
increase red blood cell production (polycythemia)) bc of intrauterine hypoxia. difficult delivery bc of increased size of the infant. birth defects. seizures as a result of the hypoxic state
58
characteristics of post term infant
the post term infant is long and thin and looks as though weight has been lost. The skin is loose esp around thighs and butt. there is little lanugo or vernix. low amt of vernix leaves skin dry, it cracks, peels, and is almost like parchment in texture. nails are long and may be staind with meconium. thick head of hair and looks alert.
59
birth defects
abnormalties that are apparent at birth.
60
`cleft lip
a fissure or an opening in the upper lip
61
cleft palate
a failure of the hard palate to fuse at the midline during the 7th to 12th weeks of gestation.
62
cheiloplasty
the initial surgical treatment for cleft lip
63
clubfoot
congenital anomaly characterized by a foot that has been twisted inward or outward.
64
congenital malformations
defects present at birth
65
erythroblastosis fetalis
Erythroblastosis fetalis is hemolytic anemia in the fetus (or neonate, as erythroblastosis neonatorum) caused by transplacental transmission of maternal antibodies to fetal red blood cells. RH negative mother and RH positive father make a RH positive baby.
66
habilitation
learning how to do something with therapy
67
hydrocephalus
increased of cerebrospinal fluid within the ventricles of the brain, which causes pressure changes in the brain and increase in head size.
68
hyperbilirubinemia
a condition in which there is too much bilirubin in the blood.
69
kernicterus
accumulation of bilirubin in the brain tissues.
70
macrosomia
large baby
71
meconium aspiration syndrome
a group of symptoms that occur when the fetus or newborn aspirates meconium stained amniotic fluid into the lungs
72
meningocele
a protrusion (tumor) of the meninges through a gap in the spine due to a congenital defects
73
meningomyelocele
protrusion of the membranes and spinal cord through this opening.
74
neonatal abstinence syndrome
happens when the fetus has prenatal exposure to drugs such as opiates, amphetamines, tranquilizers, or multiple illicit drugs while in utero.
75
myelodysplasia
also known as spina bifida, refers to a group of central nervous system disorders characterized by malformation of the spinal cord.
76
Ortolani's sign
in infants with developmental dislocation of the hip the physician can actually feel and heat the femoral head slip back into the acetabulum under gentle pressure.
77
Pavlik harness
The Pavlik Harness is a brace that is most commonly used for babies who have hip dysplasia, a hip disorder. used with infants ages 1 to 6 months to maintain the hips in a position of flexion and abduction.
78
phototherapy
a bililight provides a high intensity, narrow band of blue light that helps break down excess bilirubin.
79
RhoGAM
RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood
80
shunt
bypass the point of obstruction
81
spica cast
encircles the waist and extends to the ankles or toes
82
spina bifida
refers to a group of central nervous system disorders characterized by malformation of the spinal cord.
83
transient tachypnea of the newborn (TTN)
Usually happens after a cesarean birth or rapid vaginal delivery of a term infant. "wet lungs" or respiratory distress syndrome type 2, caused by slow absorption of the fluid in the lungs after birth.
84
transillumination
the inspection of a cavity or an organ by passing a light through its walls, useful in visualizing fluid.
85
Hydrocephalus cause, signs, symptoms, and treatment .
- results from an imbalance between production and absorption of CSF or improper formation of ventricles.
- Most commonly acquired by an obstruction or sequence of infection. Symptoms depend on location and age which it develops.
- S&S: increase head size, cranial structures seperate, veins are dilated.
- Medications to reduce production of CSF, surgery to place a shunt. (acetazolamide and furosemide)
86
prevention of neural tube defects
a multivitamin that has at least 0.4mg of folic acid until the 12th week of pregnancy and before conception.
87
nursing care for the child with meningomyelocele
- prevention of infection of or injury to the sac
- correct positioning to prevent pressure on the sac and the development of contractures
- good skin care
- adequate nutrition
- accurate observations and charting
- education of the parents
- continued medical supervision
- habilitation
**check sac size, observe for extremity deformities and movement, head circumference, observe the fontanelles, the lack of anal sphincter control and dribbling of urine are significant.
88
difference between cleft lip and cleft palate
A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the roof of the mouth contains an opening into the nose
89
symptoms of hip dysplasia
- limited abduction of the leg on the affected side
- physician can press the thigh of the normal hip backward until it almost touches the table
- the knee on the side of the dislocation is lower, and the skin folds of the thigh are deeper and often asymmetrical
- when in a prone position, one buttock appears higher than the other.
- a positive Barlow's test
- positive Ortolani's sign
* **- the most reliable sign is limited abduction of the leg on the affected side
- usually discovered during the first or second month of life
90
most common metabolic defects, causes, treatments, and care (next slide too)
* **Galactosemia
- unable to use the galactose and lactose
- enzyme needed to help the liver convert galactose is defective or missing
- it can cause cirrhosis of the liver, cataracts, and mental retardation.
- galactose is present in milk in the form of sugar so early diagnosis is essential
- S&S: lethargy, vomiting, hypotonia, diarrhea, failure to thrive, and jaundice.
- Treatment and care: milk and lactose containing products are eliminated from the diet, stop breast feeding, lactose-free formulas or soy protein based formulas are often used instead, parental support and education is essential.
* **Phenylketonuria:
- caused by faulty metabolism of phenylalanine and lack of tyrosine, it is associated with blood phenylalanine levels above 20 mg/dL, musty odor, mainly in blonde blue eyed children, may have eczema, and may have failure to thrive.
- Treatment: (Guthrie test)close dietary management and frequent evaluation of blood phenylalanine levels, synthetic food (infants: Lofenalac or Phenex-1) (children: Phenyl-free) (adolesscents:Phenex-2).
- Care: teach parents to read food labels, follow up for blood tests, referral to dietitian, and genetic counseling. (make sure to avoid aspartame(Nutrasweet) because it turns into phenylalanine.
* **Maple Syrup Urine Disease
- caused by a defect in the metabolism of branched-chain amino acids.
- results in acidosis, cerebral degeneration, and death within 2 weeks if not treated, loss of Moro reflex, hypotonia, irregular respirations, feeding difficulties, maple syrup odor urine sweat and cerumen, and convulsions.
- diagnosed by blood and urine tests
- treatment: removing the amino acids and their metabolities from the body tissues, hydration and peritoneal dialysis to decrease serum levels, lifelong diet low in amino acids leucine, isoleucine, and valine.
91
common causes of Down Syndrome, symptoms, and nursing care:
- most common cause is mothers older than 35, and fathers 55 and older.
- S&S: limp flacid posture caused by hypotonicity of muscles, close set eyes, protruding tongue, deep straight line across palm of hand (simian crease), and wide space between the 1st and 2nd toes.
- Care: Counseling parents and siblings, and make sure to show empathy.
92
There are 3 Phenotypes of Down syndrome
- -screening is available starting at 15 weeks
- -"Quad test" Alpha feta protein, hCG, unconjugated estriol, inhibin A levels are used for diagnosis
- -Amniocentesis is most accurate
* **Trisomy 21:
- most common
- there are 3 number 21 chromosomes instead of the usual 2
- results from nondisjunction (failure to seperate)
* **Mosaicism
- occurs when both normal and abnormal cells are present
- tend to be less severely affected in appearance and intelligence
* **Translocation of a chromosome
- a piece of chromosome in pair 21 breaks away and attaches itself to another chromosome.
93
causes and treatment of hemolytic disease of the newborn including phototherapy and possible complications associated with increased bilirubin levels.
* *toxic bilirubin levels (Kernicterus)
* *accumulated bilirubin in the brain tissue can cause serious brain damage and permanent disability.
- jaundice, irritability, lethargy, poor feeding, high pitched, shill cry, muscle weakness, progresses to opisthotonos, and seizures.
- cause of this is when an Rh negative mother and Rh positive father produced and Rh positive fetus.
- treatment: use of Rh(D) immune globulin (RhoGAM) administered within 72 hours of delivery with an infant that is Rh positive, an ectopic pregnancy, or after an abortion, and it may also be given to the woman at 28 weeks gestation.
- Symptoms: anemia caused by hemolysis of large # of erythrocytes, pathological jaundice within 24 hours of birth, enlargement of spleen and liver, O2 carrying capacity diminished, at risk for shock or heart failure.
- treatment: prompt identification, lab test, drug therapy, phototherapy, and exchange transfusions.
- Phototherapy reduces bilirubin levels by being placed into a a bank of fluorescent lights (blue lights) and it helps break the bilirubin down.
- nursing care: protect eyes from phototherapy, cover gonads, central line care, incubator care, observe color, apply wet and sterile compresses to the umbilicus(if ordered) until transfusions are complete.
94
describe symptoms of intracranial hemorrhage and increased intracranial pressure ( most common type of birth injury)
- can result from trauma or anoxia
- occurs more in preterm infants
- may also occur during precipitate delivery or prolonged labor
- S&S: poor muscle tone, lethargy, poor sucking reflex, respiratory distress, cyanosis, twitching, forceful vomiting, a high pitched shrill cry, and convulsions.
- The fontanelle may be tense and under pressure rather than soft and compressible.
- The pupil of one eye is likely to be small and constricted and the other large and dilated.
- Death can result if there is a massive hemorrhage, and if infant survives extensive hemorrhage may suffer residual effects, such as intellectual impairment and cerebral palsy.
95
Describe the care of the newborn whose mother had diabetes.
- Monitor: glucose levels, vital signs, signs of irritability, tremors, and respiratory distress
- glucose lower than 40mg/dL can result in rapid and permanent brain damage.
96
The baby is born with three reflexes
- Moro reflex
- rooting reflex
- tonic neck reflex
APGAR: heart rate, respirations, muscle tone, reflexes, and color
-evaluated at 1 and 5 minutes after birth
97
Jaundice is becomes evident after the second and third days of life and lasts for about 1 week.
The normal newborn will lose 10% of the birth weight within the first few days of life but returns in 10 days.
98
What is usually included in parent teaching for newborn care prior to discharge? (RESOURCE)
Return appoints for well baby care
Proper use of car safety seats
Basic infant care
99
preterm infants have poor muscle tone and less subcu fat but more vernix and lanugo than full term infants.
hypoxia: lack of oxygen ( cellular)
hypoxemia: low O2 in circulating blood
100
Premature problems: asphyxia, meconium aspiration, hypoglycemia, hypocalcemia, hemorrhage from fragile vessels, poor resistance to infection, and inadequate nutrition.
Distinguishing pathological jaundice from physiological jaundice can facilitate early intervention and prevent serious complications
101
In intracranial hemorrhage, blood vessels within the skull are broken and there is bleeding into the brain
Hyperbilirubinemia results from rapid destruction of red blood cells.
102
Vital sign changes when a newborn has increased intracranial pressure include?
-increased BP, decreased pulse and respirations
Which nursing measure is appropriate for a 2 week old newborn who has a cleft lip repair?
-Place in a car seat after each feeding
103
Meconium staining syndrome may be prevented by?
| -Reducing meconium by in amniotic fluid before birth by amnioinfusion.
What physical characteristic makes the nurse think the baby is preterm?
-superficial scalp and abdominal veins easily seen
104
Gestational age is best determined by?
| -assessment of physical and neurological characteristics
Normal glucose for a preterm infant?
| -39 mg/dL
105
The apnea monitor goes off for the preterm infant, skin is pink, HR is 130-135bpm. What should the nurse do?
-gently rub the infants back
A key nursing intervention to prevent retinopathy of prematurity is to?
-Monitor the infants blood oxygen levels.
106
Most problems of the postterm infant results from?
| -decreased functioning of the placenta
Which reflex shows the baby's reaction to sudden movement by drawing up the legs, extending the arms, then folding the arms across the chest with the fingers open?
-Moro
107
Visually, baby's prefer?
| -the human face
Why is the 2 day old babys skin yellow?
| -excess blood cells are being broken down rapidly because the baby is now breathing air.
108
3 day old daughter has blood tinged mucus vaginal discharge, why?
-effects of the mother's pregnancy hormones
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the
nurse refer to this finding when documenting?
-Cephalohematoma
109
What symptom assessed in the newborn shortly after delivery should be reported?
-Sternal or chest retractions
When the newborn’s crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back
toward the midline. How would the nurse interpret this behavior?
-The Moro reflex
110
What statement indicates the parent understands the guidelines for bathing a newborn?
-“I should shampoo the head after washing the rest of the body.”
The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal?
-An apical pulse rate of 178 beats/minute
111
A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?
-3300
The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the
most appropriate intervention by the nurse?
a. Do nothing because this is a normal occurrence.
112
Which assessment of the newborn should be reported?
| a. Head circumference is 5 cm greater than the chest circumference.
The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the
physician’s attention first?
-Bilirubin of 15
113
What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.)
- a. Swaddling
b. Rocking
c. Offering a pacifier
e. Cuddling
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which
aspects of the newborn’s physiology? (Select all that apply.)
-a. Very little subcutaneous fat
c. Ineffective sweat glands
114
Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.)
-Wash penis with warm water.
Apply diaper loosely.
```
The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.)
Blinking
Sneezing
Gagging
Sucking
```
115
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology?
(Select all that apply.)
Small glomeruli
Minimal renal blood flow
Immature renal tubules that do not concentrate urine
The nurse is assessing a preterm infant. To what does the infant’s level of maturation refer?
Ability of the organs to function outside of the uterus
116
Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?
a. Weak or absent sucking or swallowing reflex
What deficiency causes a preterm infant respiratory distress syndrome?
Surfactant
117
How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
Aspirate stomach contents.
What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?
Bradycardia
118
What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?
a. Assess for abdominal distention.
Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching
about stimulating the infant tell the parents?
-To stroke the infant during feeding to increase intake
119
The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this
infant?
a. 1 to 3 mL/kg/hr
The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to
exhibit?
-Loose, transparent skin
120
The nurse in a pediatrician’s office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36
weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth?
- 2nd
What symptoms of cold stress might the nurse recognize in a preterm infant?
-Increased respiratory rate and periods of apnea
121
How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator?
-Every 2 hours
An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will
the nurse anticipate seeing improvement of lung function?
-Within 3 days
122
The nurse knows that a postterm infant may experience which potential problems?
- a. Seizures
b. Asphyxia
e. Polycythemia
```
The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm
delivery? (Select all that apply.)
a. Placenta previa
b. Gestational diabetes
c. Pregnancy-induced hypertension
```
123
The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of ___34__ weeks.
The nurse observes that the infant’s anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the
nurse position this infant?
-In a semi-Fowler’s position
124
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
-Leave the infant in a side-lying position.
A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the priority preoperative
nursing care of this newborn?
-Position prone in an incubator.
125
The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing
abdominal girth. What is the most appropriate response?
-Notify the charge nurse of possible malabsorption.
The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report
immediately?
b. Ear infections
126
Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
-Applying elbow restraints to protect the surgical area.
An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What nursing action is the
most appropriate?
a. Feed solid foods with the spoon at the side of the mouth.
127
After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that what is the optimal time for testing
for phenylketonuria?
-After 2 to 3 days
The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest?
-Substitute Lofenalac for some protein foods
128
What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?
-Change the child’s position frequently.
Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with
a cleft lip usually undergoes surgical repair at which time?
-By 3 months of age
129
The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a
child with Down syndrome?
-Cardiovascular system
The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the most appropriate
response?
-“Cystic fibrosis is a metabolic defect.”
130
What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.)
a. Close-set eyes
b. Simian creases
d. Protruding tongue
e. Curved, small fingers
What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.)
a. Keep positioned with head elevated.
b. Feed slowly to reduce possibility of vomiting.
e. Observe for increased intracranial pressure.
131
What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired?
(Select all that apply.)
a. Keep cast uncovered to allow drying.
b. Check toes for capillary refill.
c. Circle with a pen any area of bleeding on the cast.
e. Observe for skin irritation.
The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids
during pregnancy. What would be the manifestations of this syndrome? (Select all that apply.)
a. Body tremors
b. Excessive sneezing
c. Hyperirritability
132
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.)
a. High-pitched cry
b. Unequal pupils
c. Bulging fontanelles
The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural
tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus?
(Select all that apply.)
a. Avoid drug use.
c. Take a folic acid supplement every day.
