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Flashcards in Chapter 35 Deck (30):

1. A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse’s first priority?
a. Leave the infant in the room with the mother.
b. Immediately take the infant to the nursery.
c. Perform a gestational age assessment to determine whether the infant is large for gestational age.
d. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia.

Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than 4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants. Blood glucose levels should be frequently monitored, and the infant should be closely observed for signs of hypoglycemia. Close observation can be achieved in the mother’s room with nursing interventions. However, depending on the condition of the infant, observation may be more appropriate in the nursery.


2. A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the face and upper back. Which information regarding petechiae is most accurate and should be provided to the parents?
a. Are benign if they disappear within 48 hours of birth
b. Result from increased blood volume
c. Should always be further investigated
d. Usually occur with a forceps-assisted delivery

Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of childbirth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, alarming the family is not necessary. Petechiae usually occur with a breech presentation vaginal birth.


3. What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant’s care?
a. Prone positioning facilitates bone alignment.
b. No special treatment is necessary.
c. Parents should be taught range-of-motion exercises.
d. The shoulder should be immobilized with a splint.

Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. Performing range-of-motion exercises on the infant is not necessary. A fractured clavicle does not require immobilization with a splint.


4. Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing?
a. Iron deficiency anemia
b. Hyponatremia
c. Respiratory distress syndrome
d. Sepsis

IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or sepsis.


5. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn’s distress?
a. Hypoglycemia
b. Phrenic nerve injury
c. Respiratory distress syndrome
d. Sepsis

The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually the result of traction on the neck and arm during childbirth and is not applicable to this situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy, poor feeding, irritability), not respiratory distress syndrome.


6. What is the most important nursing action in preventing neonatal infection?
a. Good handwashing
b. Isolation of infected infants
c. Separate gown technique
d. Standard Precautions

Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of health care–associated infection in nursery units. Overcrowding must be avoided in nurseries, and infants with infectious processes should be isolated. Separate gowns should be worn in caring for each infant in the special care nursery. Soiled linens should be disposed of in an appropriate manner. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Ideally infants should remain with their mothers.


7. A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant’s physical findings, this woman should be questioned about her use of which substance during pregnancy?
a. Alcohol
b. Cocaine
c. Heroin
d. Marijuana

The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.


8. For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care?
a. Administering chloral hydrate for sedation
b. Feeding every 4 to 6 hours to allow extra rest between feedings
c. Snugly swaddling the infant and tightly holding the baby
d. Playing soft music during feeding

The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because stimulation will increase activity and potentially increase CNS irritability.


9. Human immunodeficiency virus (HIV) may be transmitted perinatally or during the postpartum period. Which statement regarding the method of transmission is most accurate?
a. Only in the third trimester from the maternal circulation
b. From the use of unsterile instruments
c. Only through the ingestion of amniotic fluid
d. Through the ingestion of breast milk from an infected mother

Postnatal transmission of the HIV through breastfeeding and breast milk may occur. Transmission of the HIV from the mother to the fetus may occur through the placenta at various gestational ages. Transmission of the HIV from the use of unsterile instruments is highly unlikely; most health care facilities must meet sterility standards for all instrumentation.


10. Which substance, when abused during pregnancy, is the most significant cause of cognitive impairment and dysfunction in the infant?
a. Alcohol
b. Tobacco
c. Marijuana
d. Heroin

Alcohol abuse during pregnancy is recognized as one of the leading causes of neurodevelopmental disorders in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes; the risk for placenta previa, placenta abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of IUGR. Heroin crosses the placenta and often results in IUGR, stillbirth, and congenital anomalies.


11. During a prenatal examination, a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. The client questions the nurse as to why. What is the nurse’s most appropriate response?
a. “Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.”
b. “You and your baby can be exposed to the HIV in your cats’ feces.”
c. “It’s just gross. You should make your husband clean the litter boxes.”
d. “Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby.”

Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. Approximately 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although cleaning the litter boxes is “just gross,” this statement is not appropriate, fails to answer the client’s question, and is not the nurse’s best response. E. coli is found in normal human fecal flora and is not transmitted by cats.


12. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “What is that medicine for?” How should the nurse respond?
a. “It is an eye ointment to help your baby see you better.”
b. “It is to protect your baby from contracting herpes from your vaginal tract.”
c. “Erythromycin is prophylactically given to prevent a gonorrheal infection.”
d. “This medicine will protect your baby’s eyes from drying out over the next few days.”

With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is given to prevent infection, not for lubrication.


13. The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth?
a. Newborn’s skull is still forming and fractures fairly easily.
b. Unless a blood vessel is involved, linear skull fractures heal without special treatment.
c. Clavicle fractures often need to be set with an inserted pin for stability.
d. Other than the skull, the most common skeletal injuries are to leg bones.

Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.


14. The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate?
a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant.
b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia.
c. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests.
d. Spinal cord injuries almost always result from vacuum-assisted deliveries.

Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomographic (CT) scans might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. Spinal cord injuries are almost always from breech births; however, spinal cord injuries are rare today because cesarean birth is used for breech presentation.


15. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition?
a. Gonorrhea
b. Herpes simplex virus (HSV) infection
c. Congenital syphilis
d. HIV

A copper-colored maculopapular rash is indicative of congenital syphilis with lesions that may extend over the trunk and extremities. This rash is not an indication that the neonate has contracted gonorrhea. Rather, the neonate with gonorrheal infection might have septicemia, meningitis, conjunctivitis, and scalp abscesses. Infants affected with the HSV display growth restriction, skin lesions, microcephaly, hypertonicity, and seizures. Typically, the HIV-infected neonate is asymptomatic at birth. Most often the infant develops an opportunistic infection and rapid progression of immunodeficiency.


16. What bacterial infection is definitely decreasing because of effective drug treatment?
a. Escherichia coli infection
b. Tuberculosis
c. Candidiasis
d. Group B streptococci (GBS) infection

Penicillin has significantly decreased the incidence of GBS infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and in Canada. Candidiasis is a fairly benign fungal infection.


17. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. What is the first step in the provision of care for the infant?
a. Pharmacologic treatment
b. Reduction of environmental stimuli
c. Neonatal abstinence syndrome (NAS) scoring
d. Adequate nutrition and maintenance of fluid and electrolyte balance

NAS describes the cohort of symptoms associated with drug withdrawal in the neonate. The NAS system evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal (GI) disturbances. This evaluation tool enables the health care team to develop an appropriate plan of care. The infant is scored throughout his or her length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of the withdrawal symptoms, which are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.


18. An infant was born 2 hours ago at 37 weeks of gestation and weighs 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of what condition?
a. Birth injury
b. Hypocalcemia
c. Hypoglycemia
d. Seizures

Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.


19. Which information regarding to injuries to the infant’s plexus during labor and birth is most accurate?
a. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months.
b. Erb palsy is damage to the lower plexus.
c. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

If the nerves are stretched with no avulsion, then they should recover completely in 3 to 6 months. However, if the ganglia are completely disconnected from the spinal cord, then the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and the infant will need help from the nurse at the start.


1. A number of common drugs of abuse may cross into the breast milk of a mother who is currently using these substances, which may result in behavioral effects in the newborn. Which substances are contraindicated if the mother elects to breastfeed her infant? (Select all that apply.)
a. Cocaine
b. Marijuana
c. Nicotine
d. Methadone
e. Morphine

ANS: A, B, C
The use of cocaine, marijuana, and nicotine are contraindicated during breastfeeding because of their reported effects on the infant. Morphine is a medication often used to treat neonatal abstinence syndrome. Maternal methadone maintenance is not a contraindication to breastfeeding.


With regard to injuries to the infant’s plexus during labor and birth, nurses should be aware that:
a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
b. Erb palsy is damage to the lower plexus.
c. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

Ans: A
If the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated in facial nerve paralysis, but both mother and infant will need help from the nurse at the start.


With regard to the classification of neonatal bacterial infection, nurses should be aware that:
a. Congenital infection progresses slower than health care–associated infection.
b. Health care–associated infection can be prevented by effective handwashing; early-onset infection cannot.
c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.
d. The clinical sign of a rapid, high fever makes infection easier to diagnose.

Ans: B
Handwashing is an effective preventive measure for late-onset (health care–associated) infections because these infections come from the environment around the infant. Early-onset (congenital) infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than health care–associated (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.


Which TORCH infection could be contracted by the infant because the mother owned a cat?
a. Toxoplasmosis
b. Varicella-zoster
c. Parvovirus B19
d. Rubella

Ans: A
Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning a cat’s litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. During pregnancy, infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth; this virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).


In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:
a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.
b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys.
c. Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

Ans: C
Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident with growth, the mental capacities never become normal.


Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI?
a. Citalopram
b. Fluoxetine
c. Sertraline
d. Paroxetine

Ans: D
The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly. The absolute risk of any congenital abnormality associated with use of citalopram, fluoxetine, or sertraline is small.


An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:
a. Birth injury.
b. Hypocalcemia.
c. Hypoglycemia.
d. Seizures.

Ans: C
The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis.


Which factor increases the risk of complications for infants of diabetic mothers?
a. Glycemic control
b. Hemoglobin A1c level of 7
c. Duration of maternal disease
d. Hemoglobin A1c level of 7 prior to pregnancy

Ans: C
The duration and severity of maternal disease are significant factors in increasing the risk for complications in infants of diabetic mothers. Glycemic control would be a positive factor indicating that blood glucose levels were maintained within normal range. A hemoglobin A1c level of 7 is within normal range.


Preterm infants are more likely to become septic because:
a. IgG and IgA levels are adequate at birth.
b. Immune function is suppressed because of increased IgG levels.
c. IgG level is directly proportional to gestational age.
d. Serum complement levels are adequate.

Ans: C
IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants.


Which of the following would be considered to be an intrapartum risk factor for neonatal sepsis?
a. Mechanical ventilation
b. Chorioamnionitis
c. Galactosemia
d. Meconium aspiration

Ans: B


Which factors predispose an infant to birth injuries? (Select all that apply.)
a. Multip between the ages of 25 and 30
b. Vertex presentation
c. Application of an internal fetal scalp electrode
d. Vacuum-assisted birth

Ans: C, D
The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury. Very young age (less than 16) and older age (more than 35) in a primipara are more likely to predispose an infant to birth injuries. Vertex presentation is a normal finding and as such would not typically lead to a birth injury.