PrepU Chapter 18: Nursing Management of the Newborn

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker."

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching?

"Use talc powders to prevent diaper rash."

A nurse is teaching a newborn's parents how to change a diaper correctly. Which statement by the parents best demonstrates understanding of what they have been taught?

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

What is the expected range for respirations in a newborn?

30 to 60 breaths per minute

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate?

30 to 60 breaths/min

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Baby sleeps with the mother in bed.

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 completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal?

Clear drainage at the base of the umbilical cord

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.

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

Epstein's pearls

A nurse is changing a newborn's diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem?

Go get another pack of diapers for the bassinet from the supply closet.

Which assessment finding indicates to the nurse that a newborn has hip subluxation?

Inability of the right hip to abduct

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis

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 local hospital has a home visitation program for new families after discharge from the hospital. What benefit would this program have for parents?

It allows the parents an opportunity to demonstrate competency in caring for their infant and ask any questions.

While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as:

Jaundice

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex?

Moro

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

Suction the mouth and nose.

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.

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.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

Within one hour

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

Within the first 2 to 4 hours, when the newborn is in the nursery

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.

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

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?

erythema toxicum

A nurse is preparing to administer vitamin K to a newborn. The nurse would administer the drug by which route?

intramuscular into thigh

A nurse is preparing to administer Vitamin K to a newborn. The nurse would adminsiter the drug:

intramuscularly.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited?

rooting

While reviewing a newborn's hospital record, which of the following would be most important for you to locate?

If he breathed spontaneously at birth

A nurse is preparing to administer eye prophylaxis to a 30-minute-old newborn. Which ophthalmic medication would the nurse place in the newborn's eyes?

0.5% erythromycin eye ointment

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

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 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?

lateral to the midclavicular line at the fourth intercostal space

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset?

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

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

7 to 10.

A newborn male has just returned to the mother's room after being circumcised. What behaviors should the nurse be looking for to indicate that the newborn is in pain from the procedure?

Appearing restless and crying

A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?

Instruct the mom to feed every two to three hours.

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.

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.

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress?

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

Breastfeed the infant every 2-4 hours on demand

On inspecting a newborn's abdomen, which finding would you note as abnormal?

Clear drainage at the base of the umbilical cord suggests the child may have a patent urachus or a fistula to the bladder.

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

Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill?

Washing their hands before handling the infant

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."

When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used.

-Pink coloration is lost. -Respiratory effort decreases. -Muscle tone decreases. -Reflex irritability is noted. -Heart rate decreases.

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply.

-Place the newborn in a supine position. -Attempt to abduct the hips 180 degrees while applying upward pressure.

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply.

-Take warm-to-hot showers to encourage milk release. -Express some milk manually before breastfeeding. -Apply warm compresses to the breasts prior to nursing.

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

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute

The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period?

12 hours

A nursing supervisor calls a nurse into his office to talk to the employee. The supervisor asks the nurse if she is wearing artificial nails and the nurse responds that she is. The supervisor tells her that she must remove them for what reason?

Artificial nails harbor bacteria and increase the spread of infection.

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:

At least 24 hours after birth

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment?

Be attentive to the basic needs of the infant and be consistent.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative

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 fourth of total length

The AGPAR score is based on which 5 parameters?

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

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

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

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.

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?

Keep it dry.

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?

Mongolian spot

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

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

The nurse is caring for a newborn that weighed 7 lb 3 oz (3220 g) at birth. What action should the nurse take first based on this weight?

Plot the weight on a gestational age graph.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the eyes from vaginal bacteria

The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?

Provides blood clotting factors

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

Retracting the foreskin over the glans to assess for secretions

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

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in its bed, lying on its side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Sudden infant death syndrome

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 is experiencing moderate difficulty 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 will experience no bleeding episodes lasting more than 5 minutes.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

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.

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?

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

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 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 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