OB EX3 CHapter 18
A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse? "Be sure to keep the newborn's umbilical cord stump clean and dry." "Keep your newborn at home and do not allow visitors for the first month." "Be sure to keep all scheduled doctor appointments for vaccinations." "Always wash your hands before you pick up or provide care to your newborn."
"Always wash your hands before you pick up or provide care to your newborn."
Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "Physiologic jaundice usually begins in the first week after birth." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."
"Breastfed babies need supplements of glucose water to help lower bilirubin levels."
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? "I will feed him at least 30 cc of water daily." "I need to give him iron supplements daily." "I will give him vitamin D supplements daily for the first 2 months of life." "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation."
"I will give him vitamin D supplements daily for the first 2 months of life."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? "Change the newborn's diaper every four hours while awake." "Place the newborn on the back to sleep and stomach to play." "Newborns can sleep on a couch to allow constant visual monitoring." "You need to give your newborn a bath everyday."
"Place the newborn on the back to sleep and stomach to play."
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." Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? "He has normal male genitalia." "His testicles have not descended into the scrotal sac." "The opening of his urethra in located on the under surface of the tip of the penis." "He has fluid in the scrotal sac."
"The opening of his urethra in located on the under surface of the tip of the penis."
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 from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn on the mobile 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." Explanation: Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and
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? When the infant is 48 hours old 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents Just before discharge home
24 hours after the newborn's first protein feeding Explanation: 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.
A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term? 1,200 grams 1,800 grams 2,200 grams 3,500 grams
3,500 grams
A nurse is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters? 28 cm 30 cm 33 cm 37 cm
33 cm
During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor? A teenager who is an honor student at school A clean cut male between the age of 20 and 40 A female in her mid-20s who appears pregnant A middle-age woman who lives in another town
A female in her mid-20s who appears pregnant Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant.
What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. A washcloth Hexachlorophene soap Warm tub of water Thermometer Talc powder
A washcloth Warm tub of water Thermometer\ Explanation: The initial bath for a newborn is done using warm water, a mild soap (not hexachlorophene, which can be absorbed through the skin), and a thermometer to check the newborn's temperature following the bath. Talc powder is not recommended because of the risk for aspiration.
When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? fencing Moro tonic neck rooting
Moro
A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? Complete the hearing test. Provide hepatitis B vaccination. Administer vitamin K. Perform the newborn screening.
Administer vitamin K.
A nurse is preparing to weigh a newborn just admitted to the nursery. Place the steps listed below in the order that the nurse would complete them. Use all options. 1Balance the scale. 2Cover the scale with a warmed cloth. 3Recalibrate the scale to zero. 4Place the unclothed newborn in the center of the scale.
Balance the scale. Cover the scale with a warmed cloth. Recalibrate the scale to zero. Place the unclothed newborn in the center of the scale.
A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take? Proceed with the discharge. Notify the health care provider. Assess the bilirubin level. Assist the mother to feed the newborn.
Assess the bilirubin level. If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time.
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.
A woman who is positive for hepatitis B has just given birth to a newborn. What precaution(s) will the nurse take in caring for the mother and newborn? Select all that apply. Give the mother a one-time dose of hepatitis B immunoglobulin within 12 hours after the birth. Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth. Tell the mother that to not not breastfeed the newborn due to the infection. Admit the newborn to the hospital for several extra days for additional IV medications to treat the infection.
Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth.
The nurse is performing an assessment on a neonate. Which assessment finding should the nurse prioritize as suggestive of hypothermia? Bradycardia Hyperglycemia Metabolic alkalosis Shivering
Bradycardia Explanation: Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia.
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? Send a family member to accompany the infant when leaving the room. Check the name on the baby's identification bracelet. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.
Check the identification badge of any health care worker before releasing baby from room.
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. Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.
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? Suggest the parent stop the feeding because the newborn is full. Encourage the parent to burp the newborn to get rid of air. Urge the parent to prop the bottle for the rest of the feeding. Instruct the parent to stop feeding for a few minutes and then restart.
Encourage the parent to burp the newborn to get rid of air.
he nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: oral candidiasis (thrush). Epstein pearls. milia. vernix caseosa.
Epstein pearls.
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. Use only baby wipes to cleanse the perianal area. Use products such as talcum powder with each diaper change. Place the newborn's buttocks in warm water after each void or stool.
Expose the newborn's bottom to air several times a day. Explanation: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.
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? Rocking and talking to the infant Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back
Feeding the infant more formula whenever she begins to fuss
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? Help the mother provide skin-to-skin (kangaroo) care. Place a second stockinette on the baby's head. Administer a warm bath with temperature slightly higher than usual. Place the infant under a radiant warmer.
Help the mother provide skin-to-skin (kangaroo) care. Explanation: The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.
The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K Hep B HBV immunoglobin HiB
Hep B
he nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth Two doses of the hepatitis B immunoglobulin within 24 hours of birth
Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth
nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Administer the medication. Determine the newborn's weight. Identify the newborn. Assess the newborn for bleeding.
Identify the newborn. Explanation: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.
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. Clean the cord with soap and water, as oozing of blood is a common finding. Remove the clamp and replace with another one just above the old one. Notify the doctor to come suture the site of the bleeding.
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 silver nitrate. Instill 0.5% ophthalmic tetracycline. Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation.
Instill 0.5% ophthalmic erythromycin.
The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session? Newborns should be kept in the nursery except for feedings. Scrub your hands for 3 minutes before entering the nursery if you are wearing artificial nails. Keep all of the newborn's belongings together in the bassinet. It is acceptable to share diapers and wipes between newborns but nothing else.
Keep all of the newborn's belongings together in the bassinet.
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. Determine which hospital unit the woman works on. Inform the woman she cannot transport the baby. Ask if the client actually sent the woman.
Look at the woman's hospital identification badge.
A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? Moro reflex square window popliteal angle scarf sign
Moro reflex Explanation: There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.
The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. Nasal flaring Respiratory rate of 64 breaths per minute Bluish coloration of hands and feet Chest retractions Heart rate of 120 beats per minute
Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions
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.
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
The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Don't leave the newborn unattended unless the mother is going to the bathroom. Know when the newborn is scheduled for any tests and how long the procedure will last. Do not remove the identification bands until the newborn is discharged from the hospital. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery.
Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last Do not remove the identification bands until the newborn is discharged from the hospital.
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? Wipe the tongue off vigorously to remove the white patches. Rinse the tongue off with sterile water and a cotton swab. Since it looks like a milk curd, no action is needed. Report the finding to the pediatrician.
Report the finding to the pediatrician. Explanation: Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.
Which statement is false regarding bathing the newborn? The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing should not be done until the newborn is thermally stable. While bathing the newborn, the nurse should wear gloves. Mild soap should be used on the body and hair but not on the face.
The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply. The penis is small. There is a family history of hemophilia. The newborn was febrile at birth but temperature is now normal. The father is uncircumcised. The infant is at 33 weeks' gestation.
The infant is at 33 weeks' gestation. There is a family history of hemophilia. Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? The infant requires immediate and aggressive interventions for survival. The infant is adjusting well to extrauterine life. The infant is experiencing moderate difficulty in adjusting to extrauterine life. The infant probably has either a congenital heart defect or an immature respiratory system.
The infant is experiencing moderate difficulty in adjusting to extrauterine life. Explanation: The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 7 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.
The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn's blood glucose will remain above 50 mg/dl The newborn will experience no bleeding episodes lasting more than 5 minutes. The newborn will be correctly identified prior to separation from the parents.
The newborn will experience no bleeding episodes lasting more than 5 minutes.
A neonate born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this neonate? before feedings only if the neonate is jittery every 8 hours after feedings
before feedings
The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue? The tint is due to jaundice. Yellow is the normal color for some newborns. The infant needs to be in the sunlight to clear the skin. It's a mild reaction to the vitamin K injection.
The tint is due to jaundice.
Which newborn neuromuscular system adaptation would the nurse not expect to find? an extrusion reflex at 9 months of age a Moro reflex at 3 months of age a positive Babinski sign at 2 months of age a plantar grasp reflex at 7 months of age
an extrusion reflex at 9 months of age Explanation: An extrusion reflex usually disappears around 4 months of age. A positive Babinski sign can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.
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.
The 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
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? Perform a 3-minute surgical-type scrub. Wear clean gloves. Use infection transmission precautions. Clean hands with a betadine scrub.
Wear clean gloves.
A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? blood pressure pulse temperature respirations pain
blood pressure
While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? bruising from the birth process an immature autoregulation of blood flow an allergic reaction to the soap used for the first bath concentration of immature blood vessels
concentration of immature blood vessels Explanation: 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.
A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor? lanugo vascular nevi bruising congenital dermal melanocytosis (slate gray nevi)
congenital dermal melanocytosis (slate gray nevi) Explanation: The mark described is congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots), which occurs in ethnicities with darker colored skin. This is a normal finding that should disappear within one to tow years. It does require documentation. Lanugo is the fine hair on the newborn's body when it is born. Vascular nevi are birthmarks. Although the slate gray nevi may look like bruising, they are not.
A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition? acrocyanosis erythema toxicum yeast infection mumps
erythema toxicum Explanation: Erythema toxicum is a rash of unknown cause, with pink papules and superimposed vesicles. It appears within 24 to 48 hours after birth and resolves spontaneously in a few days. Acrocyanosis is a blue color of the hands and feet appearing in most infants at birth. Acrocyanosis may persist for 7 to 10 days. Yeast is a fungal infection caused by Candida albicans; it usually manifests in the groin. The rash of C. albicans is excoriated and does not disappear without treatment. The presentation described in this scenario is not consistent with that of mumps.
What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Initiate early and frequent breastfeeding. 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 skin-to-skin (kangaroo) care for the newborn.
initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn.
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 (PMI)? 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
Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: lanugo. vernix caseosa. milia. harlequin sign.
milia. Explanation: Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. The harlequin sign refers to a transient phenomenon in which a newborn appears red on the dependent side of the body and pale on the upper side when lying on his or her side.
A nurse is assessing a newborn's vital signs 2 hours after birth. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider? temperature 99°F (37.2°C) pulse rate 100 bpm respirations 40 breaths/min blood pressure 60/40 mm Hg
pulse rate 100 bpm
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day
temperature of 38.3° C (101° F) or higher abdominal distention refuse feeding
After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a week once a day every other day
two or three times per week