c24highrisknewbornsacquired&congenitalconditions Flashcards
(20 cards)
The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.
ANS: B
Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant’s system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and removal of bilirubin.
Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D10W. d. Document the event in the nurses’ notes.
ANS: B
These symptoms are indications of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain. It is not common practice to administer intravenous glucose to a newborn unless their condition does not allow for enteral feedings. Feeding the infant is preferable as formula or breast milk will maintain glucose stability. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.
Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome?
a.
A 35-week-gestation male baby born vaginally to a mother addicted to heroin.
b.
A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes.
c.
A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes.
d.
A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension.
ANS: C
Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.
Transitory tachypnea of the newborn (TTN) is thought to occur as a result of
a.
a lack of surfactant.
b.
hypoinflation of the lungs.
c.
inadequate absorption of fetal lung fluid.
d.
a delayed vaginal birth associated with meconium-stained fluid.
ANS: C
Inadequate absorption of fetal lung fluid is thought to be the clinical reason for TTN. Lack of surfactant in the premature infant is likely to result in respiratory distress syndrome. A delayed vaginal birth will help prevent TTN. This condition usually resolves within 24 to 48 hours. TTN is the most common respiratory cause of admissions to the NICU.
The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.
ANS: A
Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is the result of inadequate absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.
The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant?
a.
The parents spent an hour bonding with the baby after birth.
b.
An IV was started immediately after birth to treat dehydration.
c.
The infant required warmed humidified oxygen.
d.
The infant was placed skin to skin with the mother.
ANS: C
If the infant with meconium in the amniotic fluid is not breathing effectively after drying, stimulation, and bulb syringe suctioning, they may require humidified O2 or positive-pressure ventilation. Insertion of a laryngoscope and suctioning of the infant’s secretions below the vocal chords has not been found to reduce the incidence of meconium aspiration syndrome (MAS). Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Infants with this clinical presentation should be moved to a radiant warmer rather than placed skin to skin, immediately after birth. This can be done when the infant is stable.
Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn?
a.
Turn the infant every 2 hours.
b.
Place eye patches on the newborn.
c.
Wrap the infant in triple blankets to prevent cold stress.
d.
Increase the oral intake of water between and before feedings.
ANS: A
Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from accessing the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, although water should not necessarily be given. Breast milk or formula will increase the reduction of bilirubin.
Newborns whose mothers are substance abusers frequently exhibit which of the following behaviors?
a.
Hypothermia, decreased muscle tone, and weak sucking reflex
b.
Excessive sleep, weak cry, and diminished grasp reflex
c.
Circumoral cyanosis, hyperactive Babinski reflex, and constipation
d.
Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding
ANS: D
Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. These infants may also present with hyperactive muscle tone, a high-pitched cry, and diarrhea.
When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find a. cyanosis. b. diuresis. c. signs of congestive heart failure. d. increased oxygenation of the tissues.
ANS: C
Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion and congestive heart failure. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect.
In an infant with cyanotic cardiac anomaly, the nurse should expect to see
a.
feedings taken eagerly.
b.
a consistent and rapid weight gain.
c.
a decrease in the heart rate with activity.
d.
little to no improvement in color with oxygen administration.
ANS: D
With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity.
The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice
a.
may result in kernicterus.
b.
appears during the first 24 hours of life.
c.
begins on the head and progresses down the body.
d.
results from the breakdown of excessive erythrocytes not needed after birth.
ANS: B
Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. This type of jaundice may lead to kernicterus; however, screening and appropriate treatment needs to take place in a time sensitive manner in order to prevent kernicterus. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Nonphysiologic jaundice is caused by an underlying condition, such as Rh incompatibility.
Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN). The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to
a.
refer them to the neonatologist for more information.
b.
reassure them not to worry. The infant will be monitored closely by trained staff.
c.
explain to them that this often occurs following a birth and it will most likely resolve in the next 24 to 48 hours.
d.
tell them that they will be able to come and see their baby, which will help make calm their anxiety.
ANS: C
The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents’ concern without referral to the pediatric provider. Telling parents not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety; however, this does not address the parents’ knowledge deficit.
While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?
a.
Risk for infection related to release of meconium
b.
Risk for injury related to high-risk birth interventions, such as amino infusion
c.
Risk for aspiration related to retained secretions
d.
Risk for thermoregulation because of high-risk labor status
ANS: C
Because the fetus has already passed meconium in utero, the labor and birth assume a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, therefore airway complications take precedence in terms of nursing diagnosis and medical management.
Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant?
a.
Direct Coombs test based on maternal blood sample
b.
Indirect Coombs test based on infant cord blood sample
c.
Infant bilirubin level
d.
Maternal blood type
ANS: C
The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant’s bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.
Which of the following lab values indicates that an infant may have polycythemia? a. Hct 50% b. Hct 55% c. Hct 62% d. Hct 70%
ANS: D
The presence of polycythemia in an infant is characterized by a hematocrit value greater than 65%.
The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.
ANS: B
Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding.
The priority assessment for the Rh-negative infant whose mother’s indirect Coombs test was positive at 36 weeks is a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.
ANS: A
An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor due to erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated specifically to an infant with an Rh incompatibility issue.
The nurse should be alert to a blood group incompatibility if
a.
both mother and infant are O-positive.
b.
mother is A-positive and infant is A-negative.
c.
mother is O-positive and infant is B-negative.
d.
mother is B-positive and infant is O-negative.
ANS: D
Blood group incompatibilities occur because O-positive mothers who have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O.
Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth. Which viral infections are most likely to be transmitted during the birth process? (Select all that apply.) a. Hepatitis B b. Rubella c. Herpes d. Varicella Zoster e. Cytomegalovirus
ANS: A, C, E
Hepatitis B, herpes, cytomegalovirus, and HIV are usually transmitted during birth; however, they can also be acquired through transplacental transfer or from breast milk. Rubella and varicella zoster (Chickenpox) are acquired in utero and may result in fetal death or significant abnormalities.
The drug-exposed infant often presents with irritability, frantic crying, and is difficult to console. Which nursing measures can be used to prevent this behavior in this high-risk infant? (Select all that apply.) a. Keep the room well lit. b. Swaddle the infant. c. Rock slowly and gently. d. Coo softly and gently. e. Avoid pacifier use.
ANS: B, C, D
Comfort measures that will assist in consoling this infant and prevent crying include: swaddling, providing a pacifier, slow and smooth rocking in a vertical or horizontal position, cooing, gently stroking the back, keeping the room fairly dark, and avoiding both auditory and visual stimulation. These infants are particularly sensitive to light and should be placed in a darker corner of the nursery or have the lights in their room kept low. Pacifier use will assist the baby in meeting non-nutritive sucking needs and provide a method to self soothe.
