Maternal-Newborn Chapter 18 The Newborn

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? evaporation convection conduction radiation

convection

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? 6 7 8 9

6

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? "Breastfeeding takes time and practice." "Some women just can't breastfeed. Maybe I'm one of these women." "Some babies latch on and catch on quickly; others take a little more time." "Maybe a lactation specialist can help me work through this."

"Some women just can't breastfeed. Maybe I'm one of these women."

A mother asks the nurse how to swaddle her newborn because she heard that it helps infants calm down. Which statement will the nurse include in the teaching? "Infants swaddled frequently may not respond to this comfort measure." "It is best if you use the same blanket each time for swaddling." "Wrapping the infant too tightly can impaired breathing." "The infant needs to be held after she has been swaddled."

"Wrapping the infant too tightly can impaired breathing."

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: 5. 6. 7. 8.

7

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic? Wrapping of the head Developmental delay A cephalohematoma A caput succedaneum

A cephalohematoma

Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant? Taking a breath within 3 minutes of delivery with stimulation Abrupt temperature change upon delivery, causing a cry Increase in oxygen levels and decrease in CO2 levels, stimulating respirations Rapid respirations following a cesarean birth to eliminate fetal fluids

Abrupt temperature change upon delivery, causing a cry

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize? Notify the health care provider immediately. Assess the newborn for signs of respiratory distress. Reassure the parents that this is an expected pattern. Tell the parents not to worry since his color is fine.

Assess the newborn for signs of respiratory distress.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? Temperature of 97.6°F Heart rate 158 Respiratory rate 42 Blood sugar 42 mg/dL

Blood sugar 42 mg/dL

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

Conduction

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation

Convection

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? Changing the infant's diapers for the mother Demonstrating how to do cord care on the newborn Correcting the mother when she holds the newborn incorrectly. Telling the mother to feed the baby when it cries.

Demonstrating how to do cord care on the newborn

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

Document the data.

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply. Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Place the newborn in isolation precaution. Bathe the newborn thoroughly.

Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly.

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 he seems content after feeding, that should be a sign." "Make sure he drinks at least 5 minutes on each breast." "He should wet between 6 to 12 diapers each day." "If his lips are moist, then he's okay."

He should wet between 6 to 12 diapers each day."

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? Hyperbilirubinemia Respiratory distress syndrome Transient tachypnea Polycythemia

Hyperbilirubinemia

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Initiate early and frequent breast-feeding. Dry the newborn off immediately after birth to prevent chilling. Feed the newborn formula every 4 hours, starting 8 hours after birth. Feed only glucose water for the first 24 hours following birth. Begin kangaroo care for the newborn.

Initiate early and frequent breast-feeding. Dry the newborn off immediately after birth to prevent chilling. Begin kangaroo care for the newborn.

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment? Inspecting the genital area for irritated skin Inspecting if the urethral opening appears circular Palpating if testes are descended into the scrotal sac Retracting the foreskin over the glans to assess for secretions

Retracting the foreskin over the glans to assess for secretions

A young male client asks the nurse about circumcision, since he was never circumcised as an infant. Which rationale would be appropriate for exploring circumcision in an adult male? The client is experiencing premature ejaculation. The client has experienced recurring balanoposthitis and phimosis. The foreskin appears to cover the glans of the penis. His scrotum appears uneven with one testicle higher than the other.

The client has experienced recurring balanoposthitis and phimosis

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use the sealed and chilled milk within 24 hours. Use any frozen milk within 6 months of obtaining it. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? Suction the mouth and then the nose with a suction catheter. Place the newborn on its stomach with the head down and gently pat its back. Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose.

Using a bulb syringe, suction the mouth then the nose.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? bright red, raised bumpy area noted above the right eye small pink or red patches on the baby's eyelids and back of the neck fine red rash noted over the chest and back blue or purplish splotches on buttocks

bright red, raised bumpy area noted above the right eye

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? Thermoregulatory Immunological Integumentary Cardiopulmonary

cardiopulmonary

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? conduction convection radiation evaporation

conduction

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Soak the penis daily in warm water. Cover the glans generously with petroleum jelly. Cleanse the glans daily with alcohol. Notify the primary care provider if it appears red and sore.

cover the glans generously with petroleum jelly

The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? Dehydration Increased intracranial pressure Vernix caseosa Cyanosis

dehydration

The nurse is assisting new parents to adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents? Suggest they rock the baby to sleep Encourage the mother to breastfeed Commend the parents for making the right choice Encourage the parents to pick up the baby

encourage the parents to pick up the baby

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? Spinal column movement Shoulder movement Clavicles for dislocation Hip for dislocation

hip for dislocation

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority? hypothermia impaired parenting deficient fluid volume risk for infection

hypothermia

A nursing student is aware that fetal gas exchange takes place in which area? uterus placenta lungs bronchioles

placenta

The nurse is answering questions from a newborn's parents concerning a circumcision. Which structure will the nurse point out is removed during the procedure? tunica albuginea corpus spongiosum rugae prepuce

prepuce

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Providing the first bath Changing a diaper Performing a heel stick Accucheck Feeding the newborn a bottle Taking the newborn's crib to the mother's room

providing the first bath Changing a diaper Performing a heel stick Accucheck

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? respiratory rate 45 breaths/minute, irregular costal breathing pattern nasal flaring, rate 65 breaths/minute crackles on auscultation

respiratory rate 45 breaths/minute, irregular

Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean delivery? Suctioning the newborn's airway. Maintaining a thermoneutral environment. Monitor for hypoglycemia. Assessing for congenital defects.

suctioning the newborn's airway

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 normal skin finding in a newborn." "It is a sign of a group beta 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."

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." "The teeth will fall out within the first month, so don't worry about them." "The teeth will fall out when the newborn's baby teeth come in so this is a blessing."

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

After teaching a group of women about the signs of pregnancy, the nurse understands that teaching was successful if the group makes which statement? "They will be able to hear the fetal heart rate on auscultation." "The woman will have amenorrhea." "There will be a positive Hegar's sign." "The client will experience quickening."

"They will be able to hear the fetal heart rate on auscultation."

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? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "We should clean the skin with soap and water after each bowel movement" "We will fold down the front of her diaper under the umbilical cord until it falls off." "It is best practice to change the diaper every 2 to 4 hours, even during the night."

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

A nurse teaches new parents how to soothe a crying newborn. Which statement, by the parents, indicates to the nurse the teaching was effective? "We will vigorously rub our baby's back as we play some music." "We will place our baby on the belly on a blanket on the floor." "We will turn the mobile on that's hanging on our baby's crib." "We will hold feedings until our baby stops crying."

"We will turn the mobile on that's hanging on our baby's crib."

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full."

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 10% to 15% of their birth weight 5% to 10% of their birth weight 15% to 18% of their birth weight 20% of their birth weight

5-10% of their birth weight

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids? 6 to 8 4 to 6 8 to 10 2 to 4

6-8

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 between 2200 and 3000 g is considered small for gestational age. A length between 48 and 50 cm plots out at the 95th percentile for length. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. Normal birth length is usually 52 cm or above for a full-term newborn.

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

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period? Encourage to continue breast-feeding. Suggest breastfeeding be discontinued. Instruct on supplementing feedings with formula. Explain how breastfeeding will weaken the patient's condition.

Encourage to continue breast-feeding

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? Epstein's pearls milia stork bites Mongolian spots

Epstein's pearls

A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize? Immediately call the RN or health care provider. Change and bathe the infant. Check all of the baby's vital signs before calling the doctor. Explain this is normal.

Explain this is normal.

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

Fontanels

When taking the history of her postpartum patient and infant couplet, the nurse is aware which prenatal factor might have resulted in the infant being larger than average? Smoking Hypertension Gestational diabetes Poor maternal weight gain

Gestational diabetes

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. Wash it with soap and water. Apply petroleum jelly to it daily.

Keep it dry

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? Keep the environment free of color to reduce eye straining. Provide a mobile the child can see no matter how the child is turned. Place the infant's Isolette near the window so the child can see outside. Bring the child's open bassinet near the desk area so the infant sees people.

Provide a mobile the child can see no matter how the child is turned.

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. Provide warm water to drink. Provide oxygen supplementation. Massage the newborn's back. Ensure the newborn's warmth. Observe respiratory status frequently.

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

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: harlequin sign. stork bites. Mongolian spots. erythema toxic.

harlequin sign

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record? Head one half of total length Head one sixth of total length Head one fourth of total length Head one eighth of total length

head is one fourth of total length

The AGPAR score is based on which 5 parameters? heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, reflexes, and color heart rate, respiratory effort, temperature, tone, and color heart rate, breaths per minute, irritability, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: finger. heel. scalp vein. umbilical vein.

heel

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? at the third intercostal space adjacent to the midclavicular line at the midsternum, just below the suprasternal notch lateral to the midclavicular line at the fourth intercostal space at the fifth intercostal space at the right midclavicular line

lateral to the midclavicular line at the fourth intercostal space

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

limited rugae

During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby? Short neck Bowed legs Low-set ears Slanting of the palpebral fissure

low set ears

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

motor maturity

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

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: normal progression of behavior. probable hypoglycemia. physiological abnormality. inadequate oxygenation.

normal progression of behavior

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding 24 hours after admission to the nursery on admission to the nursery 4 hours after admission to the nursery

on admission to the nursery

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? Tachypnea Cardiac murmur Hypoglycemia Hyperthermia

tachypnea

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? Calling the provider immediately and reporting the findings Reassessing the newborn in 2 hours Taking no action because these are normal findings in a newborn Beginning supplemental oxygen with a nasal cannula immediately

taking no action because these are normal findings in a newborn

The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss? "We need to do a more in-depth assessment." "This is a normal response." "How often are you feeding your baby?" "You may need to supplement breast-feedings for a while."

this is a normal response

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

two smaller arteries and one larger vein

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Keep the newborn under the radiant heater when not with mom. Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Bathe and wash the newborn when temperature is 97.5° F (36.4° C)

warm all surfaces that come in contact with newborn