Move quickly from room to room and assess all clients

The Neonatal Client

1. Move quickly from room to room and assess all clients

Answers, Rationales, and Test Taking Strategies

The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.

For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.

8.

240 calories

45 mL = 1½ oz 1½ oz × 8 feedings = 12

12 × 20 calories/oz = 240 calories

CN: Physiological adaptation; CL: Apply

9.

2. Keeping the neonate away from drafts and cooling ducts prevents heat loss by convection (fl ow of heat from the body surface to the cooler sur- rounding air). The neonate also loses heat through evaporation (conversion of a liquid to a vapor, as when a wet surface, such as the neonate’s skin, is exposed to air); conduction (transfer of body heat to a cooler solid object in contact with the baby, as when the neonate comes in direct contact with a cold surface such as a scale or a cold stethoscope);

and radiation (transfer of heat to cooler solid objects that are not in direct contact with the baby, as when the neonate is placed near a cold window surface or air conditioner).

CN: Health promotion and maintenance;

CL: Apply

10.

1. To begin vitamin K synthesis, which occurs in the intestines, food and normal intestinal fl ora are needed. However, at birth, the neonate’s intestines are sterile. Therefore, vitamin K is administered via injection to prevent a vitamin K defi - ciency that may result in a bleeding tendency. When administered, vitamin K promotes formation in the liver of clotting factors II, VII, IX, and X. Neonates are not normally susceptible to clotting disorders, unless they are diagnosed with hemophilia or dem- onstrate a defi ciency of or a problem with clotting factors. Hemolysis of fetal red blood cells does not destroy vitamin K. Hemolysis may be caused by Rh or ABO incompatibility, which leads to anemia and necessitates an exchange transfusion. Vitamin K synthesis occurs in the intestines, not the liver.

CN: Pharmacological and parenteral therapies; CL: Evaluate

11.

3. Currently, the sense of touch is believed to be the most highly developed sense at birth. It is probably for this reason that neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate’s selective response to the human voice. By 4 months, the neonate should turn his eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at approximately 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood.

Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.

CN: Health promotion and maintenance;

CL: Synthesize

3.

135 mg

The recommended dose of ampicillin for a neonate is 100 mg/kg/dose. First, determine the neonate’s weight in kilograms, and then multiply the kilograms by 100 mg. The nurse should use this formula:

1,000 g = 1 kg 1,350 g = 1.35 kg 100 mg × 1.35 kg = 135 mg/kg

CN: Pharmacological and parenteral therapies; CL: Apply

4.

3. Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water loss. Bathing and the use of eye patches has no impact on insensible water loss. The use of a radiant warmer will increase the insensible water loss by drawing moisture out of the skin.

CN: Reduction of risk potential;

CL: Synthesize

5.

4. Safe practice and error reduction can be increased by double-checking orders and medica- tions before administration. Knowing the neonate’s weight, urinary output, and glucose level is an important part of understanding the potential needs of the neonate; however, double-checking orders and interventions is the most important step to increase safety.

CN: Safety and infection control;

CL: Synthesize

6.

3. Neonates that are septic use glucose at an increased rate. During the time the I.V. is not infus- ing, the neonate is using the limited glucose stores available to a preterm neonate and may deplete them. Hypoglycemia is too little glucose in the blood; without the constant infusion of I.V. glucose, hypoglycemia will result. Fevers and hyperkalemia are not related to glucose levels. Tachycardia is the result of untreated hypoglycemia.

CN: Reduction of risk potential;

CL: Analyze

7.

1. This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the fi rst few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the neonate’s intake varies from one feeding to another. Addition- ally, the neonate experiences a loss of extracellular fl uid. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the physician should be called.

CN: Health promotion and maintenance;

CL: Synthesize

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excessive air from being swallowed. The nipple is pointed directly into the mouth, not toward the neonate’s palate, to provide adequate sucking.

CN: Reduction of risk potential;

CL: Evaluate

16.

1. In a neonate, the lateral aspect of the heel is the most appropriate site for obtaining a blood specimen. Using this area prevents damage to the calcaneus bone, which is located in the middle of the heel. The middle of the heel is to be avoided because of the increased risk for damaging the calcaneus bone located there. The middle of the foot contains the medial plantar nerve and the medial plantar artery, which could be injured if this site is selected. Using the base of the big toe as the site for specimen collection would cause a great deal of discomfort for the neonate; therefore, it is not the preferred site.

CN: Reduction of risk potential;

CL: Apply

17.

2. After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop.

Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone- iodine solution may cause stinging and burning, and therefore its use is not recommended.

CN: Health promotion and maintenance;

CL: Apply

18.

2. As part of the neonate’s physiologic adaptation to birth, at 90 minutes after birth the neonate typically is in the rest or sleep phase. During this time, the heart and respiratory rates slow and the neonate sleeps, unresponsive to stimuli. At this time, the mother should rest and allow the neonate to sleep. Feedings should be given during the fi rst period of reactivity, considered the fi rst 30 minutes after birth. During this period, the neonate’s respira- tions and heart rate are elevated. Getting to know the neonate typically occurs within the fi rst hour after birth and then when the neonate is awake and

12.

1. The nurse should inform the mother that baby powder can enter the neonate’s lungs and result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is frequent diaper changing and keeping the neonate’s skin dry. The new disposable diapers have moisture- collecting materials and generally do not adhere to the skin unless the diaper becomes saturated.

Typically, allergies are not associated with the use of baby powder in neonates.

CN: Reduction of risk potential;

CL: Synthesize

13.

4. The mother needs further instruction when she says that a yellowish crust should be removed with water. The yellowish crust is normal and indicates scar formation at the site. It should not be removed, because to do so might cause increased bleeding. The petroleum gauze prevents the diaper from sticking to the circumcision site, and it may fall off in the diaper. If this occurs, the mother should not attempt to replace it but should simply apply plain petroleum jelly to the site. The gauze should be left in place for 24 hours, and the mother should continue to apply petroleum jelly with each diaper change for 48 hours after the procedure. A few drops of oozing blood is normal, but if the amount is greater than a few drops the mother should apply pressure and contact the physician.

Any bleeding after the fi rst day should be reported.

CN: Reduction of risk potential;

CL: Evaluate

14.

3. The mother demonstrates understanding of the discharge instructions when she says that she should contact the pediatrician if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehy- dration. Normally, babies fall asleep easily after a feeding because they are satisfi ed and content. Spit- ting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.

CN: Reduction of risk potential;

CL: Evaluate

15.

1. Placing the neonate on his back after the feeding is recommended to minimize the risk for sudden infant death syndrome (SIDS). Placing the neonate on the abdomen after feeding has been associated with SIDS. The mother should bubble or burp the baby after ½ oz of formula has been taken and then again when the baby is fi nished. Waiting until the baby has eaten 1 oz of formula can lead to regur- gitation. The entire nipple should be placed on top of the baby’s tongue and into the mouth to prevent

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22.

3. The neonate has a heart rate greater than 100, which earns him 2 points. His respiratory rate of 70 is equivalent to a 2 on the scale. His fl accid muscle tone is equal to 0 on the scale. The lack of response to stimulus also equals 0, as does his overall pale white color. Thus, the total score equals 4.

CN: Basic care and comfort; CL: Apply

23.

1. As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.

CN: Reduction of risk potential;

CL: Analyze

24.

2. There is a correlation between café au lait spots and the development of neurofi bromatosis.

Acrocyanosis is a normal fi nding of bluish hands and feet as a result of poor capillary perfusion. Port wine nevus and strawberry hemangiomas are a collection of dilated capillaries and are not associated with any other disease process.

CN: Reduction of risk potential;

CL: Analyze

25.

2, 3, 4. Holding the neonate steady and in the proper position will help ensure a safe and accurate lumbar puncture. The neonate is usually held in a “C” position to open the spaces between the vertebral column. This position puts the neonate at risk for airway obstruction. Thus, ensuring the patency of the airway is the fi rst priority, and the nurse should observe the neonate for adequate ventilation. Maintaining a sterile fi eld is important to avoid infection in the neonate. It is not necessary to administer antibiotics or obtain a serum glucose level during the procedure.

CN: Safety and infection control;

CL: Synthesize

26.

3. Normally, the umbilical cord has two umbilical arteries and one vein. When a neonate is born with only one artery and one vein, the nurse should notify the pediatrician for further evaluation of cardiac anomalies. Other common congenital problems associated with a missing artery include renal anomalies, central nervous system lesions, tracheoesophageal fi stulas, trisomy 13, and trisomy 18. Respiratory anomalies are associated with dyspnea and respiratory distress; musculoskeletal anomalies include fractures or dislocated hip; and facial anomalies are associated with fetal alcohol syndrome or Down syndrome, not a missing umbilical artery.

CN: Reduction of risk potential;

CL: Analyze during feedings. Changing the neonate’s diaper can

occur at any time, but at 90 minutes after birth the neonate is usually in a deep sleep, unresponsive, and probably hasn’t passed any meconium.

CN: Health promotion and maintenance;

CL: Apply

Physical Assessment of the Neonatal Client

19.

1. When assessing the incurving of the trunk tests for automatic refl exes in the newborn, the nurse places the infant horizontally and in a prone position with one hand, and strokes the side of the newborn’s trunk from the shoulder to the buttocks using the other hand. If the refl ex is present, the newborn’s trunk curves toward the stimulated side.

Answer 2 shows a fi gure for testing for a stepping response. Answer 3 shows a fi gure for testing for a tonic neck refl ex. Answer 4 shows a fi gure for testing for the Moro (startle) refl ex.

CN: Physiological adaptation; CL: Apply

20.

2. The Moro refl ex is a normal refl ex of a neonate and requires no intervention. Calling a code, placing the neonate on seizure precautions, and starting supplemental oxygen are not necessary for a normally occurring refl ex.

CN: Basic care and comfort;

CL: Synthesize

21.

2. When resuscitating the neonate, the prin- ciple of airway-breathing-circulation (ABCs) must be followed. Positioning the neonate on the back with the neck slightly extended in the “sniffi ng” position will open the airway, allowing oxygen to get to the neonate’s lungs. Apgar scores are an evaluation of the neonate’s status at 1 and 5 minutes of life. Waiting to open the airway until after assigning an Apgar score would be a waste of valuable time. If the airway is not patent, oxygen cannot be delivered. Cardiac compres- sion must be accompanied by adequate oxygenation.

CN: Physiological adaptation;

CL: Synthesize

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32.

3. The tonic neck refl ex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and fl exes the right extremities. This refl ex disappears in a matter of months as the neonatal nervous system matures. The stepping refl ex is demonstrated when the infant is held upright near a hard, fi rm surface. The prone crawl refl ex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski refl ex.

CN: Health promotion and maintenance;

CL: Apply

33.

2. Convergent strabismus is common during infancy until about age 6 months because of poor oculomotor coordination. The neonate has peripheral vision and can fi xate on close objects for short periods. The neonate can also perceive colors, shapes, and faces. Neonates can focus on light and should blink or close their eyes in response to light.

However, this is not associated with strabismus. An absent red refl ex or white areas over the pupils, not strabismus, may indicate congenital cataracts. Most neonates cannot focus well or accommodate for distance immediately after birth.

CN: Health promotion and maintenance;

CL: Apply

34.

3. A single crease across the palm (simian crease) is most commonly associated with chromo- somal abnormalities, notably Down syndrome. Deep creases across the soles of the feet is a normal fi nding in a term neonate. Frequent sneezing in a term neonate is normal. This occurs because the neonate is a nose breather and sneezing helps to clear the nares. An absence of lanugo on the skin of a term neonate is a normal fi nding.

CN: Reduction of risk potential;

CL: Synthesize

35.

1, 5, 6. Phenylketonuria, an inherited autosomal recessive disorder, involves the body’s inability to metabolize the amino acid phenylalanine.

A diet low in phenylalanine must be followed. Such foods as meats, eggs, and milk are high in phenylalanine. Assistance from a dietitian is commonly necessary to keep phenylalanine levels low and to provide the essential amino acids necessary for cell function and tissue growth. With autosomal recessive disorders, future children will have a 25% chance of having the disease, a 50% chance of carrying the disease, and a 35% chance of being free of the disease.

If a diet low in phenylalanine is followed until brain growth is complete (sometime in adolescence), the child should achieve normal intelligence.

CN: Health promotion and maintenance;

CL: Evaluate

27.

2. Normally at birth, the neonate’s head circumference is approximately 2 cm larger than the chest circumference. The average normal head circumference is 13 to 14 inches (33 to 35 cm);

average normal chest circumference is 12.5 to 14 inches (31 to 35 cm). A head circumference that is equal to or smaller than the chest circumference may indicate microcephaly; a head that is larger than normal may indicate hydrocephalus.

The presence of any of these conditions warrants further evaluation.

CN: Health promotion and maintenance;

CL: Analyze

28.

4. The mother needs further instruction if she says the molding can result in brain damage.

Brain damage is highly unlikely. Molding occurs during vaginal delivery when the cranial bones tend to override or overlap as the head accommodates to the size of the mother’s birth canal. The amount and duration of pressure on the head infl uence the degree of molding. Molding usually disappears in a few days without any special attention.

CN: Health promotion and maintenance;

CL: Evaluate

29.

3. The anterior fontanel is normally diamond- shaped, approximately 2 to 3 cm wide and 3 to 4 cm long. This allows for brain growth during the early months of life. The posterior fontanel is small and triangular.

CN: Health promotion and maintenance;

CL: Analyze

30.

3. Sole creases covering the entire foot are indicative of a term neonate. If the neonate’s ear is lying fl at against the head, the neonate is most likely preterm. An absence of rugae in the scrotum typically suggests a preterm neonate. A square window sign angle of 0 degrees occurs in neonates of 40 to 42 weeks’ gestation. A 90-degree square window angle suggests an immature neonate of approximately 28 to 30 weeks’ gestation.

CN: Health promotion and maintenance;

CL: Apply

31.

2. An expiratory grunt is signifi cant and should be reported promptly, because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts.

The presence of a red refl ex in the eyes is normal.

An absent red refl ex may indicate congenital cataracts. A respiratory rate of 45 breaths/minute and a prominent xiphoid process are normal fi ndings in a term neonate.

CN: Reduction of risk potential;

CL: Synthesize

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of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swell- ing of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

CN: Reduction of risk potential;

CL: Analyze

The Preterm Neonate

41.

1, 3, 4. Kangaroo care is skin-to-skin holding of a neonate by one of the parents. Research has shown increased bonding, physiologic stabil- ity, and decreased length of stay for neonates who experience this method of holding. Research has not shown an increase in IQ as a developmental out- come. Kangaroo care has not been shown to cause the neonate to gain weight quickly. The experience is usually limited to 1 to 2 hours, 2 to 3 times per day.

CN: Health promotion and maintenance;

CL: Apply

42.

2. The fi rst step after cesarean delivery is to aspirate mucus from the neonate’s mouth. If this is not done, the neonate will aspirate mucus when beginning to breathe. A patent airway is most important. Once mucus has been aspirated, the neonate may be stimulated to cry if necessary. If, once the airway has been established, the neonate does not begin breathing efforts on his or her own, then resuscitation may be necessary. Although the mother will want to see the neonate, holding the neonate upright is inappropriate because the neonate’s head should be kept lower than the rest of the body to aid in the expulsion of mucus or other fl uids.

CN: Health promotion and maintenance;

CL: Synthesize

43.

4. When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the “sniffi ng” or neutral position.

This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate’s shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung

36.

1. Periods of apnea lasting longer than 20 seconds, mild cyanosis, and a heart rate of 110 bpm (bradycardia) are associated with a potentially life- threatening event and subsequent respiratory arrest.

The neonate needs further evaluation by the pediatrician. Pneumonia is associated with tachycardia, anorexia, malaise, cyanosis, diminished breath sounds, and crackles. Intraventricular hemorrhage is associated with prematurity. Assessment fi ndings include bulging fontanels and seizures. Epiglottitis is a bacterial form of croup. Assessment fi ndings include inspiratory stridor, cough, and irritability. It occurs most commonly in children age 3 to 7 years.

CN: Reduction of risk potential;

CL: Analyze

37.

4. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in mental retardation. The posterior fontanel typically closes by ages 2 to 3 months.

CN: Health promotion and maintenance;

CL: Apply

38.

2. Corneas of unequal size should be reported because this may indicate congenital glaucoma. An absence of tears is common because the neonate’s lacrimal glands are not yet functioning. The neonate’s pupils normally constrict when a bright light is focused on them. The fi nding implies that light perception and visual acuity are present, as they should be after birth. A red circle on the pupils is seen when an ophthalmoscope’s light shines onto the retina and is a normal fi nding. Called the red refl ex, this indicates that the light is shining onto the retina.

CN: Reduction of risk potential;

CL: Syntehsize

39.

3. At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteri- ness, a high-pitched cry, and tremors are associated with drug withdrawal. The fi rst period of reactivity occurs in the fi rst 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate’s respiratory rate of 35 breaths/minute is normal.

CN: Health promotion and maintenance;

CL: Analyze

40.

4. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants.

Circumcision is delayed until the condition is cor- rected surgically, usually between 6 and 12 months

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