ch. 18 newborn maternity prep u

The nurse is inspecting the diaper of a newborn who has just passed meconium. The nurse would document this stool as which of the following? Seedy yellow Soft brown Sticky, forest green Formed green

Sticky, forest green

A newborn infant at 36 hours of age is jaundiced. The mother is breastfeeding. What intervention is appropriate to increase the excretion of bilirubin?

Instruct the mom to feed every two to three hours.

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? convection radiation conduction evaporation

conduction

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

Which assessment finding indicates to the nurse that a newborn has hip subluxation? crying on straightening of the right leg drawing of the legs underneath while prone inward rotation of the right foot inability of the right hip to abduct

inability of the right hip to abduct

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." "Your newborn should finish a bottle in less than 15 minutes." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? "If his lips are moist, then he's okay." "He should wet between 6 to 10 diapers each day." "Make sure he drinks at least 5 minutes on each breast." "If he seems content after feeding, that should be a sign."

"He should wet between 6 to 10 diapers each day."

After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? "The baby's mouth will open up once I put him to my breast." "I should notice a decrease in abdominal cramping during breast-feeding." "The baby can be awake or sleepy when I start to feed him." "I should wash my hands before starting to breastfeed."

"I should wash my hands before starting to breastfeed."

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is a sign of a group B streptococcus skin infection. " "It is an indication that the woman has mistreated her newborn." "It is a self-limiting virus that does not require treatment." "It is a normal skin finding in a newborn."

"It is a normal skin finding in a newborn."

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." "Covering the newborn with heavy blankets is the best way to keep your newborn warm."

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."

A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? "Urinary tract infections are more easily treated in circumcised males." "The rate of penile cancer is less for circumcised males." "Circumcision is a risk factor for acquiring HIV infection." "Sexually transmitted infections are more common in circumcised males."

"The rate of penile cancer is less for circumcised males."

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." "This can be related to cleaning her perineal area; be more careful." "If this continues, call us back; for now, just watch her." "The baby may have a problem; let's schedule an appointment."

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? You Selected: "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." Correct response: "We will fold down the front of her diaper under the umbilical cord until it falls off."

"We will fold down the front of her diaper under the umbilical cord until it falls off."

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

A nurse is caring for a breastfeeding client postpartum. The client complains of shooting nipple pain. The nurse observes that the nipples are bright red, shiny, and sore. Which of the following interventions should the nurse perform? Apply antifungal cream Apply warm water compress Apply expressed breast milk Apply a hydrogel dressing

Apply antifungal cream

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? Babinski plantar grasp stepping tonic neck

Babinski

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Bathe the baby in water between 90 and 93 degrees. Postpone breastfeeding until after the initial bath. Bathe the baby under a radiant warmer.

Bathe the baby under a radiant warmer.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? Temperature of 97.8°F Blood sugar 42 mg/dL Respiratory rate 42 Heart rate 158

Blood sugar 42 mg/dL

A new mother asks the postpartum nurse if her baby is getting enough nourishment from breastfeeding within the first 24 hours following birth. The nurse would provide her what information? Most infants need minimal nourishment for the first 24 hours, so the mother should not be concerned. Breast milk comes in within 12 hours after delivery and nourishment should not be a problem. The mother needs to supplement breastfeedings with formula until her milk comes in. Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.

Colostrum, which is the first milk produced, is rich in calories and protein that nourishes the infant well.

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? Obtain the temperature rectally. Obtain the temperature orally. Tape electronic thermistor probe to the abdominal skin. Place electronic temperature probe in the midaxillary area.

Place electronic temperature probe in the midaxillary area.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? Telling the mother to feed the baby when it cries. Correcting the mother when she holds the newborn incorrectly. Demonstrating how to do cord care on the newborn Changing the infant's diapers for the mother

Demonstrating how to do cord care on the newborn

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Put warming blanket over infant. Report tachypnea. Document normal findings. Recheck blood pressure in 15 minutes.

Document normal findings.

he nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Put warming blanket over infant. Recheck blood pressure in 15 minutes. Document normal findings. Report tachypnea.

Document normal findings.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Document the data. Call the primary care provider. Inform the charge nurse. Stimulate the neonate.

Document the data.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Stimulate the neonate. Call the primary care provider. Document the data. Inform the charge nurse.

Document the data.

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? Check the newborn's temperature. Wrap the newborn in a blanket. Dry the newborn thoroughly. Put a hat on the newborn's head.

Dry the newborn thoroughly

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Ensure the newborn's warmth. Provide warm water to drink. Observe respiratory status frequently. Massage the newborn's back. Provide oxygen supplementation.

Ensure the newborn's warmth. Observe respiratory status frequently. Provide oxygen supplementation.

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. Supplement with iron if the woman is breastfeeding. Provide supplemental water intake with feedings. Burp the newborn frequently throughout each feeding. Use feeding time for promoting closeness. Feed the newborn on demand or at least every 2 to 4 hours during the day.

Feed the newborn on demand or at least every 2 to 4 hours during the day. Burp the newborn frequently throughout each feeding. Use feeding time for promoting closeness.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Gently patting or stroking the infant's back Rocking and talking to the infant Feeding the infant more formula whenever she begins to fuss Swaddling the infant before returning to the crib

Feeding the infant more formula whenever she begins to fuss

A nurse is assessing a newborn. What gestational age assessment findings indicate that the newborn has reached term? Smooth feet with few creases Flexible wrist with a small angle at a range of 15 degrees Thick ear cartilage and a stiff pinna Abundance of fine downy lanugo

Flexible wrist with a small angle at a range of 15 degrees

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Place a gloved finger in the newborn's mouth. Turn the head to one side without moving the rest of the body. Startle the newborn by letting the head drop back slightly. Gently stroke the newborn's cheek.

Gently stroke the newborn's cheek.

The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best? Tell the parents the procedure may take more time because of the hypospadias. Continue to prepare the newborn for the procedure. Give the newborn a sucrose pacifier to reduce pain during the procedure. Inform the practitioner and cancel the procedure.

Inform the practitioner and cancel the procedure.

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse? Take no action because these are normal findings in a newborn. Begin supplemental oxygen with a nasal cannula immediately. Reassess the newborn in 2 hours. Calling the provider immediately and report the findings

Take no action because these are normal findings in a newborn.

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply. Low body temperature Irritability Jitteriness Diaphoresis Increased appetite

Low body temperature Irritability Jitteriness

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Longitudinal but no horizontal creases Creases on two-thirds of the foot Heel but no anterior creases Creases covering one fourth of the foot

Mongolian spot noted on left upper outer thigh

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Mottling noted on left upper outer thigh. Birth trauma noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh. Mongolian spot noted on left upper outer thigh.

Mongolian spot noted on left upper outer thigh

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? Offer suggestions based on observation to correct positioning or latching. Recommend a moisturizing soap to clean the nipples. Fasten nursing bra flaps immediately after feeding. Encourage use of breast pads with plastic liners.

Offer suggestions based on observation to correct positioning or latching.

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Place the newborn away from drafts and under a blanket. Explanation:

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? The oxygen in the blood decreases. Oxygen is exchanged in the lungs. Fluid is removed from the alveoli and replaced with air. Pressure changes occur and result in closure of the ductus arteriosus.

Pressure changes occur and result in closure of the ductus arteriosus.

Which action will the nurse avoid when performing basic care for a newborn male? Determining the location of the urethral opening Palpating if testes are descended into the scrotal sac Inspecting the genital area for irritated skin Retracting the foreskin over the glans to assess for secretions

Retracting the foreskin over the glans to assess for secretions

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? Notify the primary care provider if the temperature goes lower. Rewarm the newborn gradually. Assess the newborn's gestational age. Observe the newborn every hour.

Rewarm the newborn gradually.

A woman has just given birth vaginally to a newborn. Which action will the nurse do first? Determine the rectal temperature. Suction the mouth and nose. Apply identification bracelets. Assess an apical heart rate.

Suction the mouth and nose.

Which factor might result in a decreased supply of breast milk in a postpartum client? Frequent feedings An alcoholic drink Supplemental feedings with formula Maternal diet high in vitamin C

Supplemental feedings with formula

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?

The infant is attempting self-consoling maneuvers.

hat physiologic changes occur after birth when the cord is cut and clamped? The oxygenated blood coming from the placenta is diverted around the liver through the ductus venosus. The ductus ovale closes over the next 2 to 3 days. The placenta is immediately expelled. The infant takes its first breath and the lungs expand to increase blood oxygen levels.

The infant takes its first breath and the lungs expand to increase blood oxygen levels.

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? This is concerning because the swelling does not cross the newborn's suture lines. This newborn has a subarachnoid hemorrhage requiring surgical intervention. The newborn has caput succedaneum that will go away within the first week of life. This is a cephalohematoma that typically spontaneously resolves without interventions.

This is a cephalohematoma that typically spontaneously resolves without interventions.

he nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Warmer bed Glucose water Suction equipment Identification bands Ophthalmoscope

Warmer bed Suction equipment Identification bands

A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages. The nurse describes which biggest advantage? helps to ease the baby's hunger allows the baby to sleep longer allows the mother to see if the baby can tolerate formula allows the baby to pass stools, which helps to reduce bilirubin

allows the baby to pass stools, which helps to reduce bilirubin

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: have an abundant amount of subcutaneous fat all over. lose more body heat when they sweat than adults. have a smaller body surface compared to body mass. are unable to shiver effectively to increase heat production.

are unable to shiver effectively to increase heat production.

A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal? positive Ortolani sign body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) enlarged labia with pseudomenstruation asymmetrical abdomen

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

A nurse is providing care to a newborn and places a warm towel on a cold scale to prevent heat loss by which mechanism? Convection Evaporation Conduction Radiation

conduction

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? conduction convection evaporation radiation

conduction

A nurse working in the newborn nursery hears an innocent murmur on auscultation of a 24-hour-old infant's chest. The nurse recognizes this as most likely the result of which condition? attached umbilical cord stump congenital defect dysfunctional foramen ovale delayed fetal shunt closure

delayed fetal shunt closure

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? overriding of the pelvic bone slipping of the periosteal joint normal newborn variation developmental dysplasia of the hip (DDH)

developmental dysplasia of the hip (DDH)

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: nevus flammeus. erythema toxicum. port-wine stain. harlequin sign.

erythema toxicum.

nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame? first 28 days of life first 3 weeks of life first 36 days of life first 2 months of life

first 28 days of life

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess? fluid intake fontanels (fontanelles) urinary output skin turgor

fontanels (fontanelles)

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: erythema toxic. Mongolian spots. harlequin sign. stork bites.

harlequin sign.

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord? Keep it dry. Cover it with dry gauze. Apply petroleum jelly to it daily. Wash it with soap and water.

keep it dry

A nurse is teaching the mother of a newborn diagnosed with galactosemia about dietary restrictions. The nurse determines that the mother has understood the teaching when she identifies which substance as needing to be restricted? phenylalanine iodine lactose protein

lactose

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? limited rugae negative engorgement palpable testes in scrotal sac large scrotum

limited rugae

During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby? bowed legs slanting of the palpebral fissure low-set ears short neck

low set ears

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: social behaviors. orientation. habituation. motor maturity.

motor maturity.

he nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? acrocyanosis respiratory rate of 54 breaths/minute nasal flaring abdominal breathing

nasal flaring

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates: probable hypoglycemia. normal progression of behavior. inadequate oxygenation. physiological abnormality.

normal progression of behavior.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue sweating and peripheral vasoconstriction radiation, convection, and conduction

radiation, convection, and conduction

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? reflex crying response orientation to surroundings voluntary movements

reflex

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? increased intracranial pressure vaginal lacerations scalp edema cervical lacerations

scalp edema

When assessing the newborn's umbilical cord, what should the nurse expect to find? one smaller vein and two larger arteries two smaller arteries and one larger vein two smaller veins and one larger artery one smaller artery and two larger veins

two smaller arteries and one larger vein

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery

The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect? yellowish-brown, seedy stool yellow-gold, stringy stool yellowish-green, pasty stool greenish black, tarry stool

yellowish-brown, seedy stool

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? greenish black with a tarry consistency tan in color with a firm consistency yellowy mustard color with seedy appearance brownish black with a mucus-like appearanc

yellowy mustard color with seedy appearance