- A post-term pregnancy is one that extends beyond 42 weeks’ gestation. The post-term infant may be LGA, AGA, SGA, or dysmature, depending on placental function.
- The cause of prolonged pregnancy is unknown. Factors associated with postmaturity include anencephaly and trisomy 16 to 18.
- If the placenta continues to function well, the fetus will continue to grow, which results in an LGA infant who may manifest problems such as birth trauma and hypoglycemia.
- If placental function decreases, the fetus may not receive adequate nutrition. The fetus will utilize its subcutaneous fat stores for energy. Wasting of subcutaneous fat occurs, resulting in fetal dysmaturity syndrome. There are three stages of fetal dysmaturity syndrome.
- Stage 1- Chronic placental insufficiency
- Dry, cracked, peeling, loose, and wrinkled skin
- Malnourished appearance
- Open-eyed and alert baby
- Stage 2– Acute placental insufficiency
- All features of stage 1 except point iii
- Meconium staining
- Perinatal depression
- Stage 3– Subacute placental insufficiency
- Findings of stage 1 and 2 except point iii
- Green staining of skin, nails, cord, and placental membrane
- A higher risk of fetal inrapartum or neonatal death
- The newborn is at increased risk for developing complications related to compromised uteroplacental perfusion and hypoxia (e.g., meconium aspiration syndrome MAS)
- Chronic intrauterine hypoxia causes increased fetal erythropoietin and red blood cell production resulting in polycythemia.
- Post-term infants are susceptible to hypoglycemia because of the rapid use of glycogen stores.
Clinical manifestations include:
- A long, thin newborn with wasted appearance, parchment-like skin, and meconium-stained skin, nails, and umbilical cor. Fingernails are long and lanugo is absent.
- Meconium aspiration syndrome is manifested by fetal hypoxia, meconium staining of amniotic fluid, respiratory distress at delivery, and meconium-stained vocal cords.
1. Manage meconium aspiration syndrome.
- Suction the infant’s mouth and nares while the head is on the perineum and before the first breath is taken to prevent aspiration of meconium that is in the airway.
- Once the infant is dry and on the warmer, intubate with direct tracheal suctioning.
- Perform chest physiotherapy with suctioning to remove excess meconium and secretions.
- Provide supplemental oxygen and respiratory support as needed.
2. Obtain serial blood glucose measurements.
3. Provide early feeding to prevent hypoglycemia, if not contraindicated by respiratory status.
4. Maintain skin integrity.
- Keep the skin clean and dry.
- Avoid the use of powders, creams, and lotions.
- Avoid the use of tape.
Maternal & Child Practice Exam 11 (Newborn Care) PM
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When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia?
Question 1 Explanation:
Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.
A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?
Lanugo covering the body
Desquamation of the epidermis
Vernix caseosa covering the body
A sleepy, lethargic baby
Question 2 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.
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:
“Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.”
“The vitamin K will protect your infant from being jaundiced.”
“Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
“You infant needs vitamin K to develop immunity.”
Question 3 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.
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?
Increase the temperature setting on the radiant warmer
Obtain an order for IV fluid administration
Administer an oral glucose feeding of 10% dextrose in water
Wrap the neonate warmly and place her in an open crib
Question 4 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.
Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
High birth weight
Poor wake and sleep patterns
High threshold of stimulation
Question 5 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.
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding?
The primary critical observation for Apgar scoring is the:
Presence of meconium
Evaluation of the Moro reflex
Question 7 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.
The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
Question 8 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.
A baby is born precipitously in the ER. The nurses initial action should be to:
Quickly tie and cut the umbilical cord
Ascertain the condition of the fundus
Move mother and baby to the birthing unit
Establish an airway for the baby
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.
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?
Activate the code blue or emergency system
Immediately take the newborn’s temperature according to hospital policy
Do nothing because acrocyanosis is normal in the neonate
Notify the physician of the need for a cardiac consult
Question 10 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.
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:
Set up the intravenous line with 5% dextrose in water
Turn on the apnea and cardiorespiratory monitors
Connect the resuscitation bag to the oxygen outlet
Set the radiant warmer control temperature at 36.5º C (97.6ºF)
Question 11 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.
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:
Question 12 Explanation:
Milia occur commonly, are not indicative of any illness, and eventually disappear.
Within 3 minutes after birth the normal heart rate of the infant may range between:
100 and 130
100 and 180
120 and 160
130 and 170
Question 13 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.
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:
Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the infant’s mouth.
Wrap the tape measure around the infant’s head and measure just above the eyebrows.
Question 14 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.
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
Respirations, pulse, temperature
Pulse, respirations, temperature
Temperature, pulse, respirations
Respirations, temperature, pulse
Question 15 Explanation:
This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.
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?
Document the findings
Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
Contact the physician
Reinforce the dressing
Question 16 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.
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:
Instillation of the preparation into the lungs through an endotracheal tube
Question 17 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.
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
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?
Question 19 Explanation:
Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
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?
Negative Coombs test
Jaundice after the first 24 hours of life
Bleeding from the nose and ear
Jaundice within the first 24 hours of life
Question 20 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.
The nurse decides on a teaching plan for a new mother and her infant. The plan should include:
Setting up a schedule for teaching the mother how to care for her baby
Supplying the emotional support to the mother and encouraging her independence
Discussing the matter with her in a non-threatening manner
Showing by example and explanation how to care for the infant
Question 21 Explanation:
Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.
When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?
Quiet alert state
Question 22 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.
Neonates of mothers with diabetes are at risk for which complication following birth?
Question 23 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.
Which condition or treatment best ensures lung maturity in an infant?
Lecithin to sphingomyelin ratio more than 2:1
Glucocorticoid treatment just before delivery
Absence of phosphatidylglycerol in amniotic fluid
Meconium in the amniotic fluid
Question 24 Explanation:
Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
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?
Cuddles when being held
Question 25 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.
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?
Acrocyanosis and grunting
The presence of a barrel chest with grunting
Tachypnea and retractions
Hypotension and Bradycardia
Question 26 Explanation:
The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
When newborns have been on formula for 36-48 hours, they should have a:
Heel stick for blood glucose level
Test for necrotizing enterocolitis
Vitamin K injection
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.
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?
Question 28 Explanation:
Convection heat loss is the flow of heat from the body surface to the cooler air.
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
Substituting breastfeeding for formula during the 2nd day after birth
Supplementing breastfeeding with glucose water during the first 24 hours
Monitoring for the passage of meconium each shift
Instituting phototherapy for 30 minutes every 6 hours
Question 29 Explanation:
Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
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:
“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.”
“I will flush the eyes after instilling the ointment.”
“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
“I will cleanse the neonate’s eyes before instilling ointment.”
Question 30 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.
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
Group B beta-hemolytic streptococci
Question 31 Explanation:
Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.
The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
Question 32 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.
A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?
It usually resolves in 3-6 weeks
It doesn’t cross the cranial suture line
It’s a collection of blood between the skull and the periosteum
It involves swelling of tissue over the presenting part of the presenting head
Question 33 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.
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
Give the vitamin K injection
Give the initial bath
Obtain a dextrostix
Cover the neonates head with a cap
Question 34 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.
When teaching umbilical cord care to a new mother, the nurse would include which information?
Keep the cord dry and open to air
Apply peroxide to the cord with each diaper change
Cover the cord with petroleum jelly after bathing
Wash the cord with soap and water each day during a tub bath
Question 35 Explanation:
Keeping the cord dry and open to air helps reduce infection and hastens drying.
Which action best explains the main role of surfactant in the neonate?
Promotes clearing mucus from the respiratory tract
Assists with ciliary body maturation in the upper airways
Helps the lungs remain expanded after the initiation of breathing
Helps maintain a rhythmic breathing pattern
Question 36 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.
The nurse is aware that a healthy newborn’s respirations are:
Irregular, initiated by chest wall, 30-60 per minute, deep
Regular, abdominal, 40-50 per minute, deep
Irregular, abdominal, 30-60 per minute, shallow
Regular, initiated by the chest wall, 40-60 per minute, shallow
Question 37 Explanation:
Normally the newborn’s breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.
A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an examination if this neonate?
Breast bud of 1-2 mm in diameter
Leathery, cracked, and wrinkled skin
Absence of sole creases
Question 38 Explanation:
Neonatal skin thickens with maturity and is often peeling by post term.
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:
Closing the doors to the room
Turning on the overhead radiant warmer
Drying the infant in a warm blanket
Warming the crib pad
Question 39 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.
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?
Stop the breast feedings and switch to bottle-feeding permanently
Switch to bottle feeding the baby for 2 weeks
Continue to breast-feed every 2-4 hours
Feed the newborn infant less frequently
Question 40 Explanation:
Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.
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