Chapter 26: Nursing Care of a
Family with a High-Risk Newborn
Question And Answers
A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What
might the nurse observe in the newborn during routine assessment?
a. The infant may have excess of lanugo and vernix caseosa.
b. The testes in the child may be undescended.
c. The newborn may have short nails and hair.
d. The newborn may look wrinkled and old at birth. - -d. The newborn may
look wrinkled and old at birth.
Postterm babies are those born past 42 weeks' gestation. These babies
often appear wrinkled and old at birth. They often have long fingernails
and hair, dry parched skin, and no vernix caseosa. Both the quantity of
lanugo and the amount of vernix decrease with gestational age.
Undescended testes are usually not seen in postterm newborns; however,
they are highly prevalent in preterm infants.
- A 33-week-gestation infant has just been born. The child's heartbeat is
not audible. What is the priority nursing intervention?
a. Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100
times per minute
b. Administration of IV epinephrine, as prescribed
c. Transfer to a transitional or high-risk nursery for continuous cardiac
surveillance
d. Palpation for a femoral pulse - -a. Depression of the sternum with both
thumbs 1 to 2 cm at a rate of 100 times per minute
If an infant has no audible heartbeat, or if the cardiac rate is below 60
beats per minute, closed-chest massage should be started. Hold the infant
with fingers encircling the chest and wrapped around the back and
depress the sternum with both your thumbs, on the lower third of the
sternum approximately one third of its depth (1 or 2 cm) at a rate of 100
times per minute. If the pressure and the rate of massage are adequate, it
should be possible, in addition, to palpate a femoral pulse. If heart sounds
are not resumed above 60 beats per minute after 30 seconds of combined
positive-pressure ventilation and cardiac compressions, intravenous
epinephrine may be prescribed. Following cardio-resuscitation, newborns
need to be transferred to a transitional or high-risk nursery for continuous
cardiac surveillance to be certain cardiac function is maintained.
, - A 35-year-old client has just given birth to a healthy newborn during
her 43rd week of gestation. What should the nurse expect when assessing
the condition of the newborn?
a. meconium aspiration in utero or at birth
b. seizures, respiratory distress, cyanosis, and shrill cry
c. yellow appearance of the newborn's skin
d. tremors, irritability, and high-pitched cry - -a. meconium aspiration in
utero or at birth
Infants born after 42 weeks of pregnancy are post term. These infants are
at a higher risk of swallowing or aspirating meconium in utero or after
birth. As soon as the infant is born, the nurse usually suctions out the
secretions and fluids in the newborn's mouth and throat before the first
breath to avoid aspiration of meconium and amniotic fluid into the lungs.
Seizures, respiratory distress, cyanosis, and shrill cry are signs and
symptoms of infants with intracranial hemorrhage. Intracranial
hemorrhage can be a dangerous birth injury that is primarily a problem for
preterm newborns, not postterm neonates. Yellow appearance of the
newborn's skin is usually seen in infants with jaundice. Tremors, irritability,
high-pitched or weak cry, and eye rolling are seen in infants with
hypoglycemia.
- A client asks the nurse what surfactant is. Which explanation would the
nurse give as the main role of surfactant in the neonate?
a. assists with ciliary body maturation in the upper airways
b. helps maintain a rhythmic breathing pattern
c. promotes clearing of mucus from the respiratory tract
d. helps the lungs remain expanded after the initiation of breathing - -d.
helps the lungs remain expanded after the initiation of breathing
Surfactant works by reducing surface tension in the lung, which allows the
lung to remain slightly expanded, decreasing the amount of work required
for inspiration. Surfactant has not been shown to influence ciliary body
maturation, clearing of the respiratory tract, or regulation of the neonate's
breathing pattern.
- A client has given birth to a small-for-gestation-age (SGA) newborn.
Which finding would the nurse expect to assess?
a. head larger than body
b. round flushed face
c. brown lanugo body hair
d. protuberant abdomen - -a. head larger than body
A small-for-gestational-age (SGA) newborn will typically have a head that
is larger than the rest of his or her body. SGA newborns weigh below the
Family with a High-Risk Newborn
Question And Answers
A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What
might the nurse observe in the newborn during routine assessment?
a. The infant may have excess of lanugo and vernix caseosa.
b. The testes in the child may be undescended.
c. The newborn may have short nails and hair.
d. The newborn may look wrinkled and old at birth. - -d. The newborn may
look wrinkled and old at birth.
Postterm babies are those born past 42 weeks' gestation. These babies
often appear wrinkled and old at birth. They often have long fingernails
and hair, dry parched skin, and no vernix caseosa. Both the quantity of
lanugo and the amount of vernix decrease with gestational age.
Undescended testes are usually not seen in postterm newborns; however,
they are highly prevalent in preterm infants.
- A 33-week-gestation infant has just been born. The child's heartbeat is
not audible. What is the priority nursing intervention?
a. Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100
times per minute
b. Administration of IV epinephrine, as prescribed
c. Transfer to a transitional or high-risk nursery for continuous cardiac
surveillance
d. Palpation for a femoral pulse - -a. Depression of the sternum with both
thumbs 1 to 2 cm at a rate of 100 times per minute
If an infant has no audible heartbeat, or if the cardiac rate is below 60
beats per minute, closed-chest massage should be started. Hold the infant
with fingers encircling the chest and wrapped around the back and
depress the sternum with both your thumbs, on the lower third of the
sternum approximately one third of its depth (1 or 2 cm) at a rate of 100
times per minute. If the pressure and the rate of massage are adequate, it
should be possible, in addition, to palpate a femoral pulse. If heart sounds
are not resumed above 60 beats per minute after 30 seconds of combined
positive-pressure ventilation and cardiac compressions, intravenous
epinephrine may be prescribed. Following cardio-resuscitation, newborns
need to be transferred to a transitional or high-risk nursery for continuous
cardiac surveillance to be certain cardiac function is maintained.
, - A 35-year-old client has just given birth to a healthy newborn during
her 43rd week of gestation. What should the nurse expect when assessing
the condition of the newborn?
a. meconium aspiration in utero or at birth
b. seizures, respiratory distress, cyanosis, and shrill cry
c. yellow appearance of the newborn's skin
d. tremors, irritability, and high-pitched cry - -a. meconium aspiration in
utero or at birth
Infants born after 42 weeks of pregnancy are post term. These infants are
at a higher risk of swallowing or aspirating meconium in utero or after
birth. As soon as the infant is born, the nurse usually suctions out the
secretions and fluids in the newborn's mouth and throat before the first
breath to avoid aspiration of meconium and amniotic fluid into the lungs.
Seizures, respiratory distress, cyanosis, and shrill cry are signs and
symptoms of infants with intracranial hemorrhage. Intracranial
hemorrhage can be a dangerous birth injury that is primarily a problem for
preterm newborns, not postterm neonates. Yellow appearance of the
newborn's skin is usually seen in infants with jaundice. Tremors, irritability,
high-pitched or weak cry, and eye rolling are seen in infants with
hypoglycemia.
- A client asks the nurse what surfactant is. Which explanation would the
nurse give as the main role of surfactant in the neonate?
a. assists with ciliary body maturation in the upper airways
b. helps maintain a rhythmic breathing pattern
c. promotes clearing of mucus from the respiratory tract
d. helps the lungs remain expanded after the initiation of breathing - -d.
helps the lungs remain expanded after the initiation of breathing
Surfactant works by reducing surface tension in the lung, which allows the
lung to remain slightly expanded, decreasing the amount of work required
for inspiration. Surfactant has not been shown to influence ciliary body
maturation, clearing of the respiratory tract, or regulation of the neonate's
breathing pattern.
- A client has given birth to a small-for-gestation-age (SGA) newborn.
Which finding would the nurse expect to assess?
a. head larger than body
b. round flushed face
c. brown lanugo body hair
d. protuberant abdomen - -a. head larger than body
A small-for-gestational-age (SGA) newborn will typically have a head that
is larger than the rest of his or her body. SGA newborns weigh below the
