Nokea
The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infants blood glucose level is 36 mg/dL. Which action should the nurse implement?
- A. Bring the infant to the mother and initiate breastfeeding.
- B. Place a nasogastric tube and administer 5% dextrose water.
- C. Start a peripheral intravenous line and administer 10% dextrose.
- D. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.
Correct Answer: A
Rationale: A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.
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What is an important nursing intervention for a full-term infant receiving phototherapy?
- A. Observing for signs of dehydration
- B. Using sunscreen to protect the infants skin
- C. Keeping the infant diapered to collect frequent stools
- D. Informing the mother why breastfeeding must be discontinued
Correct Answer: A
Rationale: Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.
A pregnant client asks the nurse to explain the meaning of cephalopelvic disproportion. Which explanation should the nurse give to the client?
- A. It means a large for gestational age fetus.
- B. It is the narrow opening between the ischial spines.
- C. There is an uneven size between the fetus presenting part and the pelvis.
- D. The shape of the pelvis is an android shape and is unfavorable for vaginal delivery.
Correct Answer: C
Rationale: Cephalopelvic disproportion means a disproportion (or uneven size) between the fetus presenting part and the maternal pelvis. It does not mean a large for gestational age fetus or that the pelvis is an android shape. The narrow opening between the ischial spines is called the transverse measurement.
Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
- A. Hydrocephalus
- B. Cephalhematoma
- C. Caput succedaneum
- D. Subdural hematoma
Correct Answer: C
Rationale: Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp.
What is an infant with severe jaundice at risk for developing?
- A. Encephalopathy
- B. Bullous impetigo
- C. Respiratory distress
- D. Blood incompatibility
Correct Answer: A
Rationale: Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.
A newborn has been diagnosed with brachial nerve paralysis. The nurse should assist the breastfeeding mother to use which hold or position during feeding?
- A. Reclining
- B. The cradle hold
- C. The football hold
- D. The cross-over hold
Correct Answer: C
Rationale: In brachial nerve paralysis, the affected arm is gently immobilized on the upper abdomen. Tucking the newborn under the arm (football hold) puts less pressure on the newborns affected extremity. The other positions place the newborns body next to the mothers and can cause pressure on the affected arm.