Nokea
Which data should alert the nurse caring for an SGA infant that additional calories may be needed?
- A. The latest hematocrit was 53%.
- B. The infant's weight gain is 40 g/day.
- C. The infant is taking 120 mL/kg every 24 hours.
- D. Three successive temperature measurements were 36.1ï‚°C, 35.5ï‚°C, and 36.1ï‚°C (97, 96, and 97ï‚°F).
Correct Answer: B
Rationale: The correct answer is B because weight gain is a direct indicator of nutritional status. A weight gain of 40 g/day may indicate inadequate caloric intake for an SGA (small for gestational age) infant, necessitating additional calories.
A: Hematocrit level might indicate dehydration or polycythemia, not necessarily inadequate caloric intake.
C: The volume of intake alone does not indicate the adequacy of caloric intake; concentration and composition of the feed are also essential.
D: Temperature measurements are not directly related to the need for additional calories in an SGA infant.
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Which diagnosis is most common in a newborn born at 35 + 3 gestational age?
- A. Hyperglycemia
- B. Respiratory distress syndrome
- C. Infection
- D. Altered nutrition, more than body requirements
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress syndrome. At 35 + 3 weeks gestational age, the newborn's lungs may not be fully developed, leading to respiratory distress. This condition is common in premature babies due to surfactant deficiency, resulting in difficulty breathing. Hyperglycemia, infection, and altered nutrition are less likely in this scenario as they are not typically associated with prematurity at this gestational age. Respiratory distress is the most common concern in premature infants and requires prompt medical intervention to support breathing and lung function.
A newborn assessment finding that would support the nursing diagnosis of postmaturity would be
- A. loose skin.
- B. ruddy skin color.
- C. presence of vernix.
- D. absence of lanugo.
Correct Answer: A
Rationale: The correct answer is A: loose skin. Postmaturity in newborns is characterized by dry, cracked, and peeling skin due to prolonged gestation. Loose skin is a classic sign of postmaturity, indicating reduced subcutaneous fat. Ruddy skin color (B) is not specific to postmaturity. Vernix (C) is present in newborns and decreases with gestational age, not directly related to postmaturity. Lanugo (D) is fine hair that covers a fetus and sheds before birth, not a specific indicator of postmaturity.
The newborn is having occasional gasping respirations with a heart rate of 90 beats per minute. Skin color is cyanotic with poor muscle tone. Interpreting relevant clinical data in this scenario, what problems are possible? Select all that apply.
- A. The newborn is hypothermic.
- B. The newborn is full term.
- C. The newborn is experiencing respiratory distress.
- D. The newborn is anemic.
Correct Answer: C
Rationale: The correct answer is C: The newborn is experiencing respiratory distress. Gasping respirations, low heart rate, cyanotic skin, and poor muscle tone are indicative of respiratory distress in a newborn. Gasping is an abnormal breathing pattern seen in severe respiratory distress. A low heart rate is a compensatory response to decreased oxygen levels. Cyanotic skin color indicates poor oxygenation. Poor muscle tone can be a sign of inadequate oxygen delivery to tissues.
Explanation for other choices:
A: The newborn may be hypothermic due to poor temperature regulation, but the primary concern in this scenario is respiratory distress.
B: Being full term does not directly explain the newborn's clinical presentation, so it is not a likely cause.
D: Anemia could contribute to poor oxygen delivery, but the clinical presentation suggests a more acute issue related to respiratory distress.
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: The correct answer is A: cephalohematoma. Cephalohematoma is a subperiosteal collection of blood that occurs due to trauma during delivery, such as with forceps assistance. The swelling is sharply demarcated because it is bound by suture lines of the skull bones. In this case, the parietal bones are affected, while the other skull bones are not involved. The absence of edema in the neck and the infant's good activity and feeding suggest no significant underlying issues.
Summary:
B: Subgaleal hemorrhage involves bleeding into the potential space between the periosteum and the skull, resulting in diffuse swelling extending beyond suture lines.
C: Caput succedaneum is soft tissue swelling that crosses suture lines and involves the scalp, not just the parietal bones.
D: Skull fracture would present with additional signs such as crepitus, misshapen skull, or neurological deficits, which are not mentioned
Whose baby is at highest risk of developing jaundice based on risk factors?
- A. A 16-year-old mother who labored with Pitocin and had an uncomplicated delivery.
- B. A 23-year-old mother who made it to the hospital after a delivery at home, umbilical cord cut at the hospital.
- C. A 28-year-old mother with type A blood and a father with O+ blood type delivered a newborn with nuchal cord x2; forceps used
- D. A 30-year-old mother who delivered twins via cesarean section; newborn A was breech; father unknown
Correct Answer: C
Rationale: The correct answer is C because the newborn has both type A blood (from the mother) and O+ blood (from the father), leading to a higher risk of jaundice due to ABO incompatibility. The presence of nuchal cord x2 and the use of forceps during delivery also increase the risk of newborn jaundice.
Choice A is incorrect because the mother's age and use of Pitocin do not inherently increase the risk of jaundice. Choice B is incorrect because the baby being born at home and the timing of the umbilical cord cutting are not directly related to jaundice risk. Choice D is incorrect because the method of delivery and the father's unknown blood type do not specifically indicate a high risk of jaundice compared to the scenario in Choice C.