NU143- Chapter 18: Nursing Management of the Newborn

A woman has just given birth vaginally to a newborn. Which action will the nurse do first?

Suction the mouth and nose.

chest circumference

The average chest circumference is 30 to 36 cm (12 to 14 in). It is generally equal to or about 2 to 3 cm less than the head circumference

length

The average length of most newborns is 50 cm (20 in), but it can range from 44 to 55 cm (17 to 22 in)

head circumference

The average newborn head circumference is 32 to 38 cm (13 to 15 in)

Which one of the following immunizations is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B

d. Hepatitis B

tonic neck reflex

resembles the stance of a fencer and is often called the fencing reflex

RAPP assessment

respiratory activity, perfusion, and position

stork bites

salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip

babinski reflex

should be present at birth and disappears at approximately 1 year of age. It is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot

small or closed fontanels

smaller-than-normal anterior and posterior diameters or fontanels that are closed at birth

harlequin sign

the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit

breast tissue

the thickness and size of breast tissue and areola (the darkened ring around each nipple), which range from being imperceptible to full and budding

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dL (1.67 mmol/L)

Apgar score

A = appearance (color) P = pulse (heart rate) G = grimace (reflex irritability) A = activity (muscle tone) R = respiratory (respiratory effort)

pseudomenstruation

A vaginal discharge composed of mucus mixed with blood may also be present during the first few weeks of life

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?

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

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

Look at the woman's hospital identification badge.

cord care

The umbilical cord begins drying within hours after birth and is shriveled and blackened by the second or third day. Within 7 to 10 days, it sloughs off and the umbilicus heals

macrocephaly

a head circumference more than 90% of normal, typically related to hydrocephalus

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein pearls

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.

acrocyanosis

Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

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.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Wear clean gloves.

erythema toxicum

a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life

The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote: a. Conjugation of bilirubin b. Blood clotting c. Foreman ovale closure d. Digestion of complex proteins

b. Blood clotting

mongolian spots

benign blue or purple splotches that appear solitary on the lower back and buttocks of newborns, but may occur as multiple over the legs and shoulders

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

sucking reflex

elicited by gently stimulating the newborn's lips by touching them. The newborn will typically open the mouth and begin a sucking motion

caput saccedaneum

localized edema on the scalp that occurs from the pressure of the birth process

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?

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

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?

0.5

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

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman' hospital identification badge.

weight

At birth the average newborn weighs 3,400 g (7.5 lb), but normal birth weights can range from 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 13 oz).

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions.

skin condition and color

Check skin turgor by pinching a small area of skin over the chest or abdomen and note how quickly it returns to its original position

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn.

large for gestational age (LGA)

weight more than the 90th percentile on standard growth charts (usually >9 lb)

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician.

microcephaly

a head circumference more than 2 standard deviations below average or less than 10% of normal parameters for gestational age, caused by failure of brain development

ophthalmia neonatorum

a hyperacute purulent conjunctivitis occurring during the first 10 days of life. It is usually contracted during birth when the baby comes in contact with vaginal discharge of the mother infected with gonorrhea and chlamydia

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. Gonorrhea and chlamydia b. Thrush and enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes

a. Gonorrhea and chlamydia

Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths per minute c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area

a. Passage of meconium within the first 24 hours

postmature

born after 42 weeks and demonstrating signs of placental aging

postterm or postdates

born after completion of week 42 of gestation

term

born between 38 and 42 weeks' gestation

preterm or premature

born prior to 37 completed weeks' gestation, regardless of birth weight

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

rooting reflex

by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements

Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones

c. Head circumference 32 cm, chest 34 cm

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

c. Phenylketonuria

plantar creases

creases on the soles of the feet, which range from absent to covering the entire foot, depending on maturity (the greater the number of creases, the greater the newborn's maturity)

At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as: a. 5 points b. 6 points c. 7 points d. 8 points

d. 8 points

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? a. Increase surfactant levels b. Stabilize the newborn's temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin

d. Oxidize bilirubin on the skin

Moro reflex

embrace reflex, occurs when the neonate is startled. To elicit this reflex, place the newborn on his or her back

eyes and ears

eyelids can be fused or open and ear cartilage and stiffness determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the greater the newborn's maturity)

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing

The Apgar score is based on which 5 parameters?

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

stepping reflex

holding the newborn upright and inclined forward with the soles of the feet touching a flat surface. The baby should make a stepping motion or walking, alternating flexion and extension with the soles of the feet

genitals

in males, evidence of testicular descent and appearance of scrotum (which can range from smooth to covered with rugae) determine maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent clitoris with flat labia suggests prematurity, whereas a clitoris covered by labia suggests greater maturity)

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

lack of subcutaneous fat

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

cephalhematoma

localized subperiosteal collection of blood of the skull which is always confined by one cranial bone. This condition is due to pressure on the head and disruption of the vessels during birth

large fontanels

more than 6 cm in the anterior diameter bone to bone or more than a 1-cm diameter in the posterior fontanel; possibly associated with malnutrition, hydrocephaly, congenital hypothyroidism, trisomies 13, 18, and 21, and various bone disorders such as osteogenesis imperfecta

milia

multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose When they occur in a newborn's mouth and gums, they are termed Epstein pearls

A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participants correctly choose which items will be on matching identification bracelets?

newborn's sex and date and time of birth

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

nevus flammeus

port-wine stain, commonly appears on the newborn's face or other body areas

truncal incurvation reflex (Galant reflex)

present at birth and disappears in a few days to 4 weeks. With the newborn in a prone position or held in ventral suspension, apply firm pressure and run a finger down either side of the spine. This stroking will cause the pelvis to flex toward the stimulated side

skin texture

typically ranges from sticky and transparent to smooth, with varying degrees of peeling and cracking, to parchment-like or leathery with significant cracking and wrinkling

appropriate for gestational age (AGA)

weight between 10th and 90th percentiles

small for gestational age (SGA)

weight less than the 10th percentile on standard growth charts (usually >5.5 lb)

molding

can affect measurement the elongated shaping of the fetal head to accommodate passage through the birth canal

vernix caseosa

a thick white substance that protects the skin of the fetus

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: a. Respiratory distress syndrome b. Bottle mouth syndrome c. Sudden infant death syndrome d. GI regurgitation syndrome

c. Sudden infant death syndrome

lanugo

soft downy hair on the newborn's body, which is absent in preterm newborns, appears with maturity, and then disappears again with postmaturity

nevus vasculosus

strawberry mark or strawberry hemangioma, is a benign capillary hemangioma in the dermal and subdermal layers. It is raised, rough, dark red, and sharply demarcated