Newborn

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?

Elevates the gastrostomy tube

A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents?

Encourage the parents to touch their newborn.

Which would be considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of the hands and feet

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care?

Monitor skin temperature closely. .Reposition the newborn every 2 hours. .Cover the newborn's eyes with eye shields or patches.

The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern.

The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction?

"Begin with the eyes and face."

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction?

"I need to breast-feed, especially for the first 6 weeks postpartum."

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?

"Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response?

"The medication provides pain relief during labor."

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?

Edema resulting from bleeding below the periosteum of the cranium

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications?

Hypoglycemia Fractured clavicle Congenital heart defect

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition?

Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma?

Palpate the clavicles for a fracture.

The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant?

Presence of a cephalohematoma

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?

Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication?

Protect the newborn from contracting an eye infection during birth.

The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way?

Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method?

conduction

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?

constant crying

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted?

A heart rate of 140 beats/min

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn?

5

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score?

9

The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant?

90 to 150 mL

Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

BP cuff

The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant?

Periodic well-baby examinations

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage?

Phototherapy lights Intravenous (IV) pump

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route?

Phytonadione (Vitamin K)

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference?

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.

The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate?

tremors

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn?

Assessing skin integrity and fluid status of the newborn

The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure?

Immersing the newborn in water

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother?

Continue to breast-feed every 2 to 4 hours.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment?

130 beats/min

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant?

Coughing, wheezing, and short periods of apnea

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

Document the findings

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate?

40 to 60 breaths/min

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding?

A copper-colored skin rash

The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this laboratory value?

A normal value

The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted?

A respiratory rate of 40 breaths/min

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding?

A soft and flat anterior fontanel

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Contact the health care provider.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar creases

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority?

Administer oxygen via resuscitation bag to the newborn infant.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?

At 1 minute after birth and 5 minutes after birth

The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority?

Blood glucose levels

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic

A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response?

Gastric contents regurgitate back into the esophagus.

Which would be considered abnormal findings in a newborn less than 12 hours old?

Grunting respirations Heart rate of 190 beats/minute A yellow discoloration of the sclera and body

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results?

Indicates the presence of maternal infection

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note?

Irritability

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate?

Notify the health care provider (HCP).

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions?

The mother bathes the newborn infant after a feeding. (may cause regurgitation)

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine?

The newborn requires some resuscitative interventions.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action?

Thoroughly dry the newborn.