Neonatal Assessment

Neonatal Assessment

Question 1: Neonatal assessment: You, the student nurse, are performing an assessment on a 3-hour neonate and hear a murmur upon auscultation. 3 points

1. Is this an expected finding?
2. If yes, then explain.
3. What fetal circulatory structure does this clinical manifestation relate to?

Murmurs are an expected finding. Most of them are not pathological and can disappear after the neonate becomes six months (Durham & Chapman, 2014). The circulatory structures associated with murmurs are the ductus venosus, foramen ovale, and the ductus arteriosus ((Durham & Chapman, 2014)

Question 2: NCLEX: Nursing care of the neonate post-delivery.A healthy neonate was just delivered in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? SELECT one answer below. SELECT the best answer. (1 point)

1. Place the infant under a radiant warmer
2. Place the infant skin-to-skin with the mother (Durham & Chapman, 2014).
3. Obtain a healing stick to assess for hypoglycemia.

Question 3: NCLEX: Nursing care of the neonate post-delivery. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? (1 point)

1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer.

Question 4: Nursing care of the neonate post-delivery: The nurse prepares to administer a vitamin K injection to a newborn. The mother asks the nurse why her infant needs the injection. How should the nurse respond to the patient’s mother? (2 points)

Vitamin K is administered to the newborn to prevent hemorrhagic disease due to vitamin K deficiency (Durham & Chapman, 2014).

Question 5: Neonatal assessment: Lara is a full-term (2-day old/ 5.5 lb.) neonate with a urinary output of 55mL for 24 hours. (6 points)

1. Is this normal for Lara?
2. What is Lara’s expected urinary output range for 24 hours? Please provide the upper and lower range.
3. Why is a neonate at increased risk for water intoxication or over-hydration?

The urine output is normal. The urinary output range is 15-60mL/kg per day (Durham & Chapman, 2014). Neonates are at increased risk of water intoxication due to decreased glomerular filtration rate (Durham & Chapman, 2014)

Question 6: NCLEX: Neonatal assessment: A full-term neonate is admitted to the normal newborn nursery. The nurse notes a normal Moro reflex. What should the nurse do next? 1 point

1. Call a code
2. Identify this reflex as a normal finding
3. Place the neonate on seizure precautions
4. Start supplemental oxygen.

Question 7: Neonatal assessment: Apgars

1. What does an Apgar score of 0-3 indicate? 1 point
2. What does an Apgar score of 4-6 indicate? 1 point
3. What does an Apgar score of 7-10 indicate? 1 point

Fill in the chart below.

Apgar 0-3	Severe distress
Apgar 4-6	Moderate difficulty with transitioning to extrauterine life
Apgar 7-10	Stable status

Question 8: Nursing care of the neonate post-delivery (Blood glucose levels): The neonatal nurse practitioner alerts you that Jaya, a 3-hour-old neonate, is exhibiting signs and symptoms of hypoglycemia and asks you to obtain a blood glucose reading. List 3 assessment findings on Jaya that would correlate with this diagnosis. (3 points)

Blood glucose of less than 40mg/dl

Irritability

Tremors (Durham & Chapman, 2014)

Question 9: NCLEX: Nursing care of the neonate post-delivery (blood glucose levels). The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate’s foot near which of the following areas? Please indicate where you would obtain your sample and why. (2 points)

The edges of the heels on the media and the outside. These areas are minimally invasive.

Question 10: Neonatal assessment: Why is hypoglycemia common immediately after birth in neonates of diabetic mothers? 2 points

This is due to high levels of insulin produced by neonates due to high maternal glucose levels. The high insulin levels persist even after delivery, causing hypoglycemia (Durham & Chapman, 2014).

 Question 11: Neonatal assessment: What is a neonate’s optimal range for plasma glucose? (2 points)

70-100 mg/dL (Durham & Chapman, 2014).

Question 12: Nursing care of the neonate post-delivery (circumcision): List one serious complication of circumcision. (2 points)

Infections ((Durham & Chapman, 2014)

Question 13: NCLEX: Nursing care of the neonate post-delivery (circumcision): After circumcision, the nurse instructs the neonate’s mother to cleanse the circumcision with which of the following? (1 point)

1. Antibacterial soap
2. Warm water
3. Povidone-iodine (Betadine) solution
4. Diluted hydrogen peroxide

Question 14: NCLEX: Nursing care of the neonate (cord care): The mother of the newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and reddened and that discharge was present. What is the most appropriate nursing instruction for this mother? (1 point)

1. Bring the infant to the clinic (Durham & Chapman, 2014).
2. This is a normal occurrence.
3. Increase the number of times that the cord is cleaned per day
4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues

Question 15: Neonatal assessment: List 2 respiratory assessments that would indicate that a neonate is having respiratory distress. (2 points)

Longer periods of apnea greater than 15-20 seconds

Retractions of the chest wall (Durham & Chapman, 2014).

Question 16: NCLEX: Nursing care of the neonate post-delivery (Erythromycin). The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? (1 point)

1. Protects the newborn’s eyes from possible infections acquired while hospitalized.
2. It prevents cataracts in newborns born to a woman susceptible to rubella.
3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
4. Prevents an infection called ophthalmia neonatorum from occurring after the delivery in a newborn born to a woman with an untreated gonococcal infection.

Question 17: Nursing care of the neonate post-delivery (Erythromycin). Please use the document posted to Canvas to answer this question (Ball & Bindler, 2012)

1. What position could you place yourself and the neonate to administer Erythromycin ophthalmic ointment to prevent the neonate’s hands from interfering with medication administration? (2 points)
2. True or False (referring to Erythromycin ophthalmic administration). Apply a 1-2 cm (half-inch) line of ointment into the upper conjunctival sac, working from the outer to the inner canthus. (1 point)
3. If the answer to the letter B is false, then change the information above to reflect a true statement. (2 points)

Tilt the child’s head back (National Health Service, 2020). Part B is true.

Question 18: NCLEX: Assessment of the high-risk neonate (Respiratory distress syndrome: preterm neonate). The newborn nursery nurse monitors a late preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? (1 point)

1. Tachypnea and retractions (Durham & Chapman, 2014)
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest and acrocyanosis

Question 19: Nursing care of the high-risk neonate (BPD). You are a nurse caring for a neonate who is diagnosed with Bronchopulmonary Dysplasia (BPD). The healthcare provider orders a bronchodilator, a corticosteroid, and a diuretic. List 1 physical assessment finding that would indicate the efficacy of each medication for a patient diagnosed with BPD. 6 points (2 each)

Medication	List 1 physical assessment that would indicate the efficacy of medication for a patient with BPD.
Bronchodilator	No wheezing or rhonchi
Corticosteroid	Reduced bronchospasm
Diuretic	No wheezing

Question 20: NCLEX: Assessment of a high-risk neonate (PVH/IVH). Which of the following would the nurse most expect to assess in a neonate delivered at 28 weeks gestation who is diagnosed with intraventricular hemorrhage (IVH)? (1 point)

1. Increased muscle tone
2. Hyperbilirubinemia
3. Bulging fontanels (Durham & Chapman, 2014)
4. Hyperactivity

Question 21: Assessment of high-risk neonates (PVH/IVH). List one risk factor to PVH/IVH in the above scenario from question # 22. (1 point)

Premature birth at less than 34 weeks of gestation (Durham & Chapman, 2014).

Question 22: NCLEX: Assessment of the high-risk neonate (phototherapy). While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted? (1 point)

1. Bronze-colored skin (Durham & Chapman, 2014).
2. Maculopapular chest rash
3. Urine specific gravity of 1.018
4. Absent Moro reflex

Question 23: Nursing care of the high-risk neonate (GBS). Two hours ago, a neonate at 38 weeks gestation and weighing 7lbs was born to a primiparous patient who tested positive for beta-hemolytic Streptococcus (GBS). The neonate is febrile, and the blood cultures confirm GBS. The mother was not treated with antibiotics during her pregnancy. List one antibiotic you can anticipate the HCP to order. (1 point)

Penicillin G

References

Durham, R., & Chapman, L. (2014). Maternal-newborn nursing: The critical components of nursing care (2nd ed.). F.A. Davis.

National Health Service. (2020). How to give your child eye ointment. GOSH Hospital site. https://www.gosh.nhs.uk/conditions-and-treatments/medicines-information/how-give-your-child-eye-ointment/

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Chapman, L. & Durham, R. (2014). Maternal Newborn Nursing: The Critical Components of Nursing
Care. (2 ed.). Philadelphia, PA: F.A. Davis Company. CHAPTERS 15-17

1. Neonatal assessment: You, the student nurse, are assessing a 3-hour neonate and hear a murmur upon auscultation. 3 points
A. Is this an expected finding?
B. If yes, then explain.
C. What fetal circulatory structure does this clinical manifestation relate to?

2. NCLEX: Nursing care of the neonate post-delivery.
A healthy neonate was just delivered in stable condition. In addition to drying the infant, what is the preferred method to prevent heat loss? SELECT one answer below. SELECT the best answer. 1 point
A. Place the infant under a radiant warmer B. Place the infant skin-to-skin on the mother. C. Obtain a healing stick to assess for hypoglycemia

3. NCLEX: Nursing care of the neonate post-delivery.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1 point
A. Warming the crib pad
B. Closing the doors to the room
C. Drying the infant with a warm blanket
D. Turning on the overhead radiant warmer

4. Nursing care of the neonate post-delivery: The nurse prepares to administer a vitamin K injection to a newborn. The mother asks the nurse why her infant needs the injection. How should the nurse respond to the patient’s mother? 2 points