Ch. 18 MCN Course Point

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding. The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs?

2pm The nurse needs to complete vital signs every half hour for the first 2 hours of life.

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?

5

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of:

7 The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).

When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction?

Cooperation by the parents with the hospital policies

It is common for a newborn to have one or two erupted teeth (natal teeth) at birth.

False

You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.?

If the infant has more than two episodes of diarrhea in one day Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the physician if the newborn has more than two episodes of diarrhea in one day

A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take?

Instill antibiotic 0.5 percent erythromycin

When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse?

Lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention?

Redness at the base of the umbilical cord The cord should dry and fall off in the 7 to 10 days after delivery. If the cord base changes color or develops drainage the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for two hours or more each day and straining at stools are normal in a newborn

On an Apgar evaluation, reflex irritability is tested by which of the following?

Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?

The first 6 months

While teaching a student, the nurse should include which of the following signs and symptoms to recognize hypoglycemia in the neonate? (Select all that apply.)

• Jitteriness • Tachypnea • Poor feeding Signs and symptoms of hypoglycemia in newborns include jitteriness or tremors, exaggerated Moro reflex, irritability, lethargy, poor feeding, listlessness, apnea, respiratory distress including tachypnea, and a high-pitched cry.

When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching?

"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." Newborn males who are circumcised have higher rates of skin dehiscence, adhesions, and urethral fistulas.

A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which of the following would be the total Apgar score for this newborn?

8 The heart rate of 110, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8.

(see full question) Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs?

Blood Pressure Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal AGPARs. It is assessed if there is a clinical indication such as suspected blood loss or low APGAR scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.

A nurse, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

Concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish- purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

The nurse is orienting a student to the nursery. Which statement by the student indicates that the teaching has been effective? "The signs of neonate respiratory distress include: (Select all that apply.)

Signs of respiratory distress in the newborn include tachypnea, nasal flaring, grunting, intercostal or xiphoid retractions, retractions, unequal movements of the chest and abdomen during breathing efforts, and central cyanosis; Incorrect C: blue hands and feet is called acrocyanosis. This condition is caused by poor peripheral circulation, not respiratory distress. & HR over 100bpm??

With a hepatitis B (HbsAG) positive mother, what should the newborn receive?

The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth If a mother has hepatitis B or is suspected of having hepatitis B, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immuoglobulin within 12 hours of birth

GA based on neurologic maturity

The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear

Which of the following is FALSE regarding bathing the newborn?

To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn?

Warm all surfaces and objects that come in contact with the newborn. The infant will have regulated the body temperature at this point in life. Interventions to prevent heat loss are the best way to prevent heat loss for this newborn. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?

a) "I will give him vitamin D supplements daily for the first 2 months of life." As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water.

A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply.

• Take warm-to-hot showers to encourage milk release • Express some milk manually before breastfeeding • Apply warm compresses to the breasts prior to nursing massage toward nipples To relieve breast engorgement in the client, the nurse should educate the client to take warm-to-hot showers to encourage milk release, express some milk manually before breastfeeding, and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions—sitting up and then lying down. The breasts should be massaged from under the axillary area, down toward the nipple