Preterm Newborn Nursing Care Plan & Management

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Notes

Description

A preterm newborn is one born before 37 weeks’ gestation.

Etiology

The etiology of preterm labor is poorly understood.
Possible factors include the following:
1. Multiple gestation
2. Maternal history of preterm delivery
3. Hydramnios
4. Uterine anomalies
5. More than one second trimester abortion
6. Incompetent cervix
7. Infection
8. Uterine structural anomalies
9. Premature rupture of membranes
10. Maternal substance abuse (especially cocaine).
11. Maternal age less than 18 years , poor nutrition, and lack of prenatal care

Pathophysiology

Preterm newborns exhibit anatomic and physiologic immaturity in all body systems; this immaturity hinders the adaptations to extrauterine life that the newborn must make.

Assessment Findings

1. Associated findings. Altered parenting as evidenced by:

Decreased or absent parental visits
Parental resistance or refusal to participate in newborn care
Denial of severity of newborn illness
Resistance or refusal to touch newborn
Persistent verbalization of guilt

2. Clinical manifestations. There is a higher risk for the following manifestations with a younger gestational age.

Respiratory manifestations include tachypnea, grunting, nasal flaring, retractions, cyanosis, decreased oxygen saturation, decreased oxygen levels, and abnormal arterial blood gas (ABG) values.
Cardiovascular manifestations include poor tissue perfusion, hypotension, and patent ductus arteriosus.
Gastrointestinal manifestations include feeding intolerance, gastric reflux, vomiting, and gastric residuals.
Altered fluid status may be manifested by fluid excess or fluid deficit.
- Fluid excess is manifested by edema and congestive heart failure.
- Fluid deficit is manifested by tachycardia, poor skin turgor, decreased urine output, abnormal electrolyte levels, and decreased blood pressure.
Iatrogenic anemia secondary to blood sampling may be present. It is exhibited by tachycardia, pallor, decreased blood pressure, increasing oxygen requirements, and apnea.
Infection may occur.
Hypoglycemia or hyperglycemia may be present.
Ineffective temperature control may be observed, and is exhibited by an inability to maintain core body temperature.
Neuromuscular system manifestations include decreased suck and swallow reflex, hypotonia, and altered state transition.
Hyperbilirubinemia is characterized by rapid destruction of red blood cells, jaundice, and lethargy. Kernicterus is the deposition of unconjugated bilirubin in the brain cells and is associated with mental retardation.

Nursing Management

1. Provide respiratory support (see Drug Chart)

2. Perform the following assessments.

Assess heart sounds for presence of murmurs.
Assess pulse and perfusion.
Monitor blood pressure, heart rate, and pulse pressures.

3. Provide adequate fluids and electrolytes and nutrition.

4. Maintain a neutral thermal environment.

5. Prevent infection.

6. Assess for readiness for selected interventions.

Provide stimulation when appropriate to infant state and readiness.
Encourage flexion in the supine position by using blanket rolls.
Provide the newborn with body boundaries through swaddling or using blanket rolls against the newborn’s body and feet.

7. Promote parent-newborn attachment.

8. Initiate phototherapy as required.

DRUG CHART Medications Used for Postpartum Complications

Classifications	Used for	Selected Interventions
Lung surfactant Beractant (Survanta)	Restores naturally occurring lung surfactant to improve lung compliance Used to prevent or treat respiratory distress syndrome in premature infants	The usual dose is 4 mL/kg intratracheally in 4 doses at least 6 hours apart in the first 48 hours of life. Suction the infant’s airway before administration and delay further suctioning as long as possible. Assess the infant’s respiratory rate, arterial blood gases, and color before administration. Change the infant’s position every 2 hours to promote flow to both lungs. Assess the infant’s respiratory rate, color, and arterial blood gases after administration. Monitor for side effects, which may include transient bradycardia or rales.

Exam

Maternal & Child Practice Exam 11 (Newborn Care) PM

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Question 1

Which action best explains the main role of surfactant in the neonate?

A	Helps maintain a rhythmic breathing pattern
B	Promotes clearing mucus from the respiratory tract
C	Assists with ciliary body maturation in the upper airways
D	Helps the lungs remain expanded after the initiation of breathing

Question 1 Explanation:

Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

Question 2

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?

A	Wrap the neonate warmly and place her in an open crib
B	Administer an oral glucose feeding of 10% dextrose in water
C	Increase the temperature setting on the radiant warmer
D	Obtain an order for IV fluid administration

Question 2 Explanation:

Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.

Question 3

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?

A	Hypotension and Bradycardia
B	Tachypnea and retractions
C	Acrocyanosis and grunting
D	The presence of a barrel chest with grunting

Question 3 Explanation:

The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

Question 4

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?

A	Hypoactivity
B	High threshold of stimulation
C	Poor wake and sleep patterns
D	High birth weight

Question 4 Explanation:

Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.

Question 5

Within 3 minutes after birth the normal heart rate of the infant may range between:

A	120 and 160
B	100 and 180
C	100 and 130
D	130 and 170

Question 5 Explanation:

The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.

Question 6

The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:

A	50
B	80
C	100
D	60

Question 6 Explanation:

The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.

Question 7

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:

A	Substituting breastfeeding for formula during the 2nd day after birth
B	Monitoring for the passage of meconium each shift
C	Supplementing breastfeeding with glucose water during the first 24 hours
D	Instituting phototherapy for 30 minutes every 6 hours

Question 7 Explanation:

Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.

Question 8

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:

A	“You infant needs vitamin K to develop immunity.”
B	“The vitamin K will protect your infant from being jaundiced.”
C	“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
D	“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”

Question 8 Explanation:

Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.

Question 9

A baby is born precipitously in the ER. The nurses initial action should be to:

A	Establish an airway for the baby
B	Quickly tie and cut the umbilical cord
C	Ascertain the condition of the fundus
D	Move mother and baby to the birthing unit

Question 9 Explanation:

The nurse should position the baby with head lower than chest and rub the infant’s back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.

Question 10

The primary critical observation for Apgar scoring is the:

A	Evaluation of the Moro reflex
B	Presence of meconium
C	Respiratory rate
D	Heart rate

Question 10 Explanation:

The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.

Question 11

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:

A	Warming the crib pad
B	Turning on the overhead radiant warmer
C	Drying the infant in a warm blanket
D	Closing the doors to the room

Question 11 Explanation:

Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

Question 12

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?

A	It doesn’t cross the cranial suture line
B	It usually resolves in 3-6 weeks
C	It’s a collection of blood between the skull and the periosteum
D	It involves swelling of tissue over the presenting part of the presenting head

Question 12 Explanation:

Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.

Question 13

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?

A	Nitrogen loss
B	Hypoglycemia
C	Anemia
D	Thrombosis

Question 13 Explanation:

Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.

Question 14

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to:

A	Set up the intravenous line with 5% dextrose in water
B	Set the radiant warmer control temperature at 36.5º C (97.6ºF)
C	Turn on the apnea and cardiorespiratory monitors
D	Connect the resuscitation bag to the oxygen outlet

Question 14 Explanation:

The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

Question 15

A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?

A	Incessant crying
B	Sleepiness
C	Lethargy
D	Cuddles when being held

Question 15 Explanation:

A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

Question 16

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the student states:

A	“I will flush the eyes after instilling the ointment.”
B	“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
C	“I will cleanse the neonate’s eyes before instilling ointment.”
D	“Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.”

Question 16 Explanation:

Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication.

Question 17

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?

A	Reinforce the dressing
B	Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
C	Contact the physician
D	Document the findings

Question 17 Explanation:

A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.

Question 18

Neonates of mothers with diabetes are at risk for which complication following birth?

A	Pneumothorax
B	Atelectasis
C	Macrosomia
D	Microcephaly

Question 18 Explanation:

Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

Question 19

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:

A	Subcutaneous injection
B	Instillation of the preparation into the lungs through an endotracheal tube
C	Intramuscular injection
D	Intravenous injection

Question 19 Explanation:

The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

Question 20

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as:

A	Mongolian spots
B	Lanugo
C	Whiteheads
D	Milia

Question 20 Explanation:

Milia occur commonly, are not indicative of any illness, and eventually disappear.

Question 21

A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?

A	Vernix caseosa covering the body
B	Desquamation of the epidermis
C	A sleepy, lethargic baby
D	Lanugo covering the body

Question 21 Explanation:

Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate.

Question 22

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?

A	Shivering
B	Metabolic alkalosis
C	Bradycardia
D	Hyperglycemia

Question 22 Explanation:

Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

Question 23

A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?

A	Leathery, cracked, and wrinkled skin
B	Absence of sole creases
C	Breast bud of 1-2 mm in diameter
D	Abundant lanugo

Question 23 Explanation:

Neonatal skin thickens with maturity and is often peeling by post term.

Question 24

The nurse is aware that a healthy newborn’s respirations are:

A	Regular, initiated by the chest wall, 40-60 per minute, shallow
B	Irregular, abdominal, 30-60 per minute, shallow
C	Irregular, initiated by chest wall, 30-60 per minute, deep
D	Regular, abdominal, 40-50 per minute, deep

Question 24 Explanation:

Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.

Question 25

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:

A	Respirations, pulse, temperature
B	Temperature, pulse, respirations
C	Pulse, respirations, temperature
D	Respirations, temperature, pulse

Question 25 Explanation:

This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.

Question 26

A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately:

A	Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
B	Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
C	Wrap the tape measure around the infant’s head and measure just above the eyebrows.
D	Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes

Question 26 Explanation:

To measure the head circumference, the nurse should place the tape measure under the infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included.

Question 27

When newborns have been on formula for 36-48 hours, they should have a:

A	Heel stick for blood glucose level
B	Vitamin K injection
C	Test for necrotizing enterocolitis
D	Screening for PKU

Question 27 Explanation:

By now the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early detection can determine if the liver enzyme is absent.

Question 28

When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?

A	Give the initial bath
B	Cover the neonates head with a cap
C	Obtain a dextrostix
D	Give the vitamin K injection

Question 28 Explanation:

Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after birth.

Question 29

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?

A	Continue to breast-feed every 2-4 hours
B	Stop the breast feedings and switch to bottle-feeding permanently
C	Switch to bottle feeding the baby for 2 weeks
D	Feed the newborn infant less frequently

Question 29 Explanation:

Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

Question 30

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?

A	Milia
B	Nevus flammeus
C	Lanugo
D	Vernix

Question 31

The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?

A	Chlamydia trachomatis
B	Group B beta-hemolytic streptococci
C	Escherichia coli
D	Candida albicans

Question 31 Explanation:

Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.

Question 32

After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?

A	Hypoglycemia
B	Jitteriness
C	Respiratory depression
D	Tachycardia

Question 32 Explanation:

Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.

Question 33

The nurse decides on a teaching plan for a new mother and her infant. The plan should include:

A	Supplying the emotional support to the mother and encouraging her independence
B	Discussing the matter with her in a non-threatening manner
C	Setting up a schedule for teaching the mother how to care for her baby
D	Showing by example and explanation how to care for the infant

Question 33 Explanation:

Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.

Question 34

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?

A	Hiccups
B	Gaze aversion
C	Quiet alert state
D	Yawning

Question 34 Explanation:

When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

Question 35

When teaching umbilical cord care to a new mother, the nurse would include which information?

A	Apply peroxide to the cord with each diaper change
B	Cover the cord with petroleum jelly after bathing
C	Wash the cord with soap and water each day during a tub bath
D	Keep the cord dry and open to air

Question 35 Explanation:

Keeping the cord dry and open to air helps reduce infection and hastens drying.

Question 36

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?

A	Triceps
B	Deltoid
C	Vastus lateralis
D	Biceps

Question 37

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?

A	Bleeding from the nose and ear
B	Jaundice within the first 24 hours of life
C	Jaundice after the first 24 hours of life
D	Negative Coombs test

Question 37 Explanation:

The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.

Question 38

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?

A	Immediately take the newborn’s temperature according to hospital policy
B	Activate the code blue or emergency system
C	Do nothing because acrocyanosis is normal in the neonate
D	Notify the physician of the need for a cardiac consult

Question 38 Explanation:

Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.

Question 39

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?

A	Conduction
B	Convection
C	Radiation
D	Evaporation

Question 39 Explanation:

Convection heat loss is the flow of heat from the body surface to the cooler air.

Question 40

Which condition or treatment best ensures lung maturity in an infant?

A	Absence of phosphatidylglycerol in amniotic fluid
B	Glucocorticoid treatment just before delivery
C	Meconium in the amniotic fluid
D	Lecithin to sphingomyelin ratio more than 2:1

Question 40 Explanation:

Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.

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