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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.
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The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia. Which route of administration should be used?
- A. Oral
- B. Intramuscular
- C. Intravenous
- D. Intraosseous
Correct Answer: C
Rationale: Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion. If it is given more rapidly than this, cardiac dysrhythmias and circulatory collapse may occur. Early feedings are indicated, but when the ionized calcium drops below 3.0 to 4.4 mg/dL, intravenous calcium gluconate is necessary. Intramuscular or intraosseous administration is not recommended.
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.
The parents of a newborn ask the nurse what caused the babys facial nerve paralysis. The nurses response is based on remembering that this is caused by what?
- A. Birth injury
- B. Genetic defect
- C. Spinal cord injury
- D. Inborn error of metabolism
Correct Answer: A
Rationale: Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to the nerve. Genetic defects, spinal cord injuries, and inborn errors of metabolism did not cause the facial nerve paralysis. The paralysis usually disappears in a few days but may take as long as several months.
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?
- A. 2 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. After the fifth day
Correct Answer: C
Rationale: Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.
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.