Chapter 26: Nursing Care of a Family with a High-Risk Newborn

Chapter 26: Nursing Care of a Family with a High-Risk Newborn The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? a. 20th b. 9th c. 5th d. 95th - ANS a. 20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight. What is a consequence of hypothermia in a newborn? a. respirations of 46 b. heart rate of 126 c. holds breath 25 seconds d. skin pink and warm - ANS c. holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia. A nurse is providing care to a large-for-gestational-age newborn. The newborn's blood glucose level was 32 mg/dl one hour ago. Breastfeeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dl. Which action would the nurse do next? a. Administer intravenous glucose. b. Feed the newborn 2 ounces of formula. c. Initiate blow-by oxygen therapy. d. Place the newborn under a radiant warmer. - ANS a. Administer intravenous glucose Supervised breastfeeding or formula feeding may be the initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. If hypoglycemia persists, then intravenous dextrose may be needed. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dl. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? a. Deep inspiration b. Expiratory lag c. Sternal retraction d. Inspiratory grunt - ANS c. Sternal retraction