Maternity / Newborn
The nurse prepares to administer a phytonadione (vitamin K) injection to a
newborn, and the mother asks the nurse why her infant needs the injection. What
best response should the nurse provide?
"Your newborn needs the medicine to develop immunity."
"The medicine will protect your newborn from being jaundiced."
"Newborns have sterile bowels, and the medicine promotes the growth of
bacteria in the bowel."
"Newborns are deficient in vitamin K, and this injection prevents your
newborn from bleeding."
Rationale:
Phytonadione is necessary for the body to synthesize coagulation factors. It
is administered to the newborn to prevent bleeding disorders. It also promotes liver
formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K–
deficient because the bowel does not have the bacteria necessary to synthesize fat-
soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The
newborn's bowel does not support the normal production of vitamin K until
bacteria adequately colonize it. The bowel becomes colonized by bacteria as food
is ingested. Vitamin K does not promote the development of immunity or prevent
the infant from becoming jaundiced.
, The nurse is monitoring a preterm newborn for respiratory distress syndrome
(RDS). Which finding in the newborn should alert the nurse to the possibility of
this syndrome?
Tachypnea and retractions
Acrocyanosis and grunting
Hypotension and bradycardia
The presence of a barrel chest and acrocyanosis
Rationale:
The neonate with RDS may present with clinical signs of cyanosis,
tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory
grunts. Acrocyanosis is the bluish discoloration of the hands and feet and is not
uncommon in the first few hours of life. The findings noted in the remaining
options do not indicate clinical signs of RDS.
The nurse in the delivery room is performing an initial assessment on a
newborn infant. When examining the umbilical cord, the nurse observes only 2
vessels. How should the nurse interpret this finding?
Finding 2 vessels is the expected finding.
Finding 2 vessels is correlated to a high incidence of Down syndrome.
, Finding 2 vessels may indicate an increased risk for other congenital
anomalies.
Finding 2 vessels means the newborn has been stressed previously with fetal
hypoxia.
Rationale:
The umbilical cord is made up of 2 arteries to carry blood from the embryo
to the chorionic villi and 1 vein that returns blood to the embryo. Whenever a
congenital anomaly occurs in a newborn, there is an increased risk for other
congenital anomalies. Finding 2 vessels is not what is expected. There is not a
direct correlation between 2 umbilical vessels and Down syndrome. Fetal hypoxia
in utero will not cause the absence of an umbilical vessel.
The nurse is creating a plan of care for a newborn diagnosed with fetal
alcohol syndrome. The nurse should include which priority intervention in the plan
of care?
Allow the newborn to establish own sleep-rest pattern.
Maintain the newborn in a brightly lighted area of the nursery.
Encourage frequent handling of the newborn by staff and parents.
Monitor the newborn's response to feedings and weight gain pattern.
, Rationale:
Fetal alcohol syndrome, a diagnostic category delineated under fetal alcohol
spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy.
A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is
to establish nutritional balance after birth. These newborns may exhibit
hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing
ability. A quiet environment with minimal stimuli and handling would help to
establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3
are inappropriate interventions.
The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions should be included in the plan of care? Select all that apply.
Avoid stimulation.
Decrease fluid intake.
Expose all of the newborn's skin.
Monitor skin temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
Rationale:
The nurse prepares to administer a phytonadione (vitamin K) injection to a
newborn, and the mother asks the nurse why her infant needs the injection. What
best response should the nurse provide?
"Your newborn needs the medicine to develop immunity."
"The medicine will protect your newborn from being jaundiced."
"Newborns have sterile bowels, and the medicine promotes the growth of
bacteria in the bowel."
"Newborns are deficient in vitamin K, and this injection prevents your
newborn from bleeding."
Rationale:
Phytonadione is necessary for the body to synthesize coagulation factors. It
is administered to the newborn to prevent bleeding disorders. It also promotes liver
formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K–
deficient because the bowel does not have the bacteria necessary to synthesize fat-
soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The
newborn's bowel does not support the normal production of vitamin K until
bacteria adequately colonize it. The bowel becomes colonized by bacteria as food
is ingested. Vitamin K does not promote the development of immunity or prevent
the infant from becoming jaundiced.
, The nurse is monitoring a preterm newborn for respiratory distress syndrome
(RDS). Which finding in the newborn should alert the nurse to the possibility of
this syndrome?
Tachypnea and retractions
Acrocyanosis and grunting
Hypotension and bradycardia
The presence of a barrel chest and acrocyanosis
Rationale:
The neonate with RDS may present with clinical signs of cyanosis,
tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory
grunts. Acrocyanosis is the bluish discoloration of the hands and feet and is not
uncommon in the first few hours of life. The findings noted in the remaining
options do not indicate clinical signs of RDS.
The nurse in the delivery room is performing an initial assessment on a
newborn infant. When examining the umbilical cord, the nurse observes only 2
vessels. How should the nurse interpret this finding?
Finding 2 vessels is the expected finding.
Finding 2 vessels is correlated to a high incidence of Down syndrome.
, Finding 2 vessels may indicate an increased risk for other congenital
anomalies.
Finding 2 vessels means the newborn has been stressed previously with fetal
hypoxia.
Rationale:
The umbilical cord is made up of 2 arteries to carry blood from the embryo
to the chorionic villi and 1 vein that returns blood to the embryo. Whenever a
congenital anomaly occurs in a newborn, there is an increased risk for other
congenital anomalies. Finding 2 vessels is not what is expected. There is not a
direct correlation between 2 umbilical vessels and Down syndrome. Fetal hypoxia
in utero will not cause the absence of an umbilical vessel.
The nurse is creating a plan of care for a newborn diagnosed with fetal
alcohol syndrome. The nurse should include which priority intervention in the plan
of care?
Allow the newborn to establish own sleep-rest pattern.
Maintain the newborn in a brightly lighted area of the nursery.
Encourage frequent handling of the newborn by staff and parents.
Monitor the newborn's response to feedings and weight gain pattern.
, Rationale:
Fetal alcohol syndrome, a diagnostic category delineated under fetal alcohol
spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy.
A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is
to establish nutritional balance after birth. These newborns may exhibit
hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing
ability. A quiet environment with minimal stimuli and handling would help to
establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3
are inappropriate interventions.
The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions should be included in the plan of care? Select all that apply.
Avoid stimulation.
Decrease fluid intake.
Expose all of the newborn's skin.
Monitor skin temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
Rationale:
