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Which infant is at greatest risk for developing hypoglycemia after birth?
- A. Severe small for gestational age infant
- B. Appropriate for gestational age infant
- C. Infant of a diabetic mother with maternal glucose control
- D. Cold-stressed term infant
Correct Answer: A
Rationale: The correct answer is A: Severe small for gestational age (SGA) infant, as they have limited glycogen stores and are at higher risk for hypoglycemia. SGA infants often have poor growth in utero, leading to decreased nutrient reserves. This puts them at increased risk for low blood sugar levels after birth.
Incorrect choices:
B: Appropriate for gestational age infants typically have adequate glycogen stores and are at lower risk for hypoglycemia.
C: Infants of diabetic mothers with good maternal glucose control are less likely to have hypoglycemia due to stable blood sugar levels in utero.
D: Cold-stressed term infants may have transient hypoglycemia, but they are not at the greatest risk compared to severe SGA infants.
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An infant weight is documented as being in the 90th percentile. What does the RN understand about this measurement?
- A. The infant’s weight is appropriate or average.
- B. The 90th percentile indicates LGA.
- C. Infants in the 90th percentile will be overweight as adults.
- D. The infant’s weight is less than 90% of all other infants’ weights.
Correct Answer: C
Rationale: The correct answer is C because being in the 90th percentile for weight as an infant does not necessarily mean the weight is appropriate or average (choice A) or that the infant is LGA (choice B). Choice D is incorrect because being in the 90th percentile means the infant's weight is greater than 90% of other infants, not less. Choice C is correct because research shows that infants in the 90th percentile for weight are more likely to be overweight as adults due to potential genetic factors and lifestyle habits developed early in life.
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
The postnatal nurse is providing care for a neonate being treated with phototherapy for hyperbilirubinemia. For which side effects of phototherapy will the nurse contact the neonatal care provider? Select all that apply.
- A. Hyperthermia
- B. Lethargy
- C. Hypocalcemia
- D. Thrombocytopenia
Correct Answer: A
Rationale: The correct answer is A: Hyperthermia. During phototherapy, neonates are at risk for developing hyperthermia due to the heat generated by the lights. The nurse should contact the provider if the neonate shows signs of hyperthermia to prevent complications.
B: Lethargy is not a direct side effect of phototherapy but can be a result of other factors such as inadequate feeding or underlying medical conditions.
C: Hypocalcemia is not a common side effect of phototherapy. It is more often associated with other conditions or treatments.
D: Thrombocytopenia is not a typical side effect of phototherapy. It refers to low platelet levels and is usually not directly related to phototherapy treatment.
The nurse is providing care for a premature neonate in the NICU nursery. The neonate is diagnosed with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Which specific intervention does the nurse expect for this neonate?
- A. Monitor of hemoglobin and hematocrit levels.
- B. Obtain blood glucose levels.
- C. Maintain fluid restrictions.
- D. Administer enteral feedings.
Correct Answer: C
Rationale: The correct answer is C: Maintain fluid restrictions. For a neonate with BPD and PDA, fluid restrictions are essential to prevent fluid overload and worsening of the conditions. Excessive fluid can exacerbate pulmonary edema in BPD and increase cardiac workload in PDA. Monitoring hemoglobin and hematocrit levels (A) is important but not specific to these conditions. Obtaining blood glucose levels (B) is important for monitoring overall health but not specific to BPD and PDA. Administering enteral feedings (D) may be necessary but does not directly address the primary concern of fluid management in these conditions.
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.