OB Prep U CH. 18 [For EXAM 3]

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."

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:

Acrocyanosis.

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.

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'll turn the mobile on that's hanging above his head in his crib."

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

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?

Concentration of immature blood vessels

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies

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?

Cover the glans generously with petroleum jelly.

The 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:

Epstein's 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.

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

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.

The parents of a newborn male ask the nurse about circumcision. They are undecided as to what to do. Which response by the nurse is best?

"I recommend you discuss the pros and cons of circumcision with the newborn's health care provider."

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 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?

"Place the newborn on the back to sleep and stomach to play."

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?

"Use talc powders to prevent diaper rash."

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

A nurse is assessing a newborn's gestational age, When determining neuromuscular maturity, which parameters would the nurse assess? Select all that apply.

- Arm recoil - Scarf sign

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which signs might indicate a problem? Select all that apply.

- Labored breathing - Generalized cyanosis - Flaccid body posture

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 oxygen supplement. -Ensure the newborn's warmth -Observe respiratory status frequently

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

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10.

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 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?

Assess the newborn for signs of respiratory distress.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose.

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.

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

Epstein's pearls

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 kangaroo care

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping?

Hold the newborn upright with the newborn's head on the mother's shoulder

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn.

The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5oF (37.5oC), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs?

In 30 minutes

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions

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 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.

The African American parents are spending time with their newborn after the nurse brings the baby back from the transition nursery. The parents are horrified to note that their infant's buttocks appears bruised and demand to know what happened. The nurse should explain this is related to which factor?

Mongolian spots

A nurse is aware that the newborn's neuromuscular maturity 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

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?

Place electronic temperature probe in the midaxillary area

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.

A nurse is conducting an refresher program for a group of nurses returning to work in the newborn clinic. The nurse nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional teaching is needed when the group identifies which parameter as being included in the assessment?

blood pressure

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

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

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 AGPAR score is based on which 5 parameters?

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

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding?

nevus flammeus

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?

right upper abdominal quadrant

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

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

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm