PrepU Newborn Assessment (Ch 18)
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 122 beats/minute 132 beats/minute 140 beats/minute
108 beats/minute normal range is 110-160
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 aquamephyton. Perform the newborn screening.
Administer aquamephyton. aquamephyton is the same as vitamin K!
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. Ask how long the infant will be gone since her next feeding is in 30 minutes. Ask the woman to bring the infant back when the doctor finishes the examination. Call the nursery to confirm the doctor does indeed need this infant at this time.
Ask to see the woman' hospital identification badge.
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. Place child in a radiant warmer. Assess the baby's temperature. Assess for pain source.
Check blood glucose.
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? Instruct the parent to stop feeding for a few minutes and then restart. Urge the parent to prop the bottle for the rest of the feeding. Encourage the parent to burp the newborn to get rid of air. Suggest the parent stop the feeding because the newborn is full.
Encourage the parent to burp the newborn to get rid of air.
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. Since it looks like a milk curd, no action is needed. Rinse the tongue off with sterile water and a cotton swab. Wipe the tongue off vigorously to remove the white patches.
Report the finding to the pediatrician.
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 infant probably has either a congenital heart defect or an immature respiratory system. The infant is adjusting well to extrauterine life. The infant requires immediate and aggressive interventions for survival.
The infant is experiencing moderate difficulty in adjusting to extrauterine life.
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? heart rate temperature blood sugar Apgar score
blood sugar
A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug: subcutaneously. orally. intravenously. intramuscularly.
intramuscularly.
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? the first 28 days the first 3 months the first 4 months the first 6 months
the first 6 months
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 all scheduled doctor appointments for vaccinations." "Be sure to keep the newborn's umbilical cord stump clean and dry." "Always wash your hands before you pick up or provide care to your newborn." "Keep your newborn at home and do not allow visitors for the first month."
"Always wash your hands before you pick up or provide care to your newborn."
A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems." "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins."
"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."
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) 70 mg/dl (3.89 mmol/L) 50 mg/dl (2.77 mmol/L) 90 mg/dl (5.00 mmol/L)
30 mg/dl (1.67 mmol/L)
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 Convective Radiating Conductive
Evaporative
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 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? Administer a warm bath with temperature slightly higher than usual. Place a second stockinette on the baby's head. Place the infant under a radiant warmer. Help the mother provide kangaroo care.
Help the mother provide kangaroo care.
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Using a 21-gauge needle Injecting 1cc of medication Injecting at a 45-degree angle Injecting the medication into the vastus lateralis
Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc's of medication at a 90-degree angle.
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Notify the doctor to come suture the site of the bleeding. Remove the clamp and replace with another one just above the old one. Clean the cord with soap and water, as oozing of blood is a common finding. Inspect the clamp to insure that it is tightly closed and applied correctly.
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 tetracycline. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation.
Instill 0.5% ophthalmic erythromycin.
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh.
A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used. 1Transfer the newborn to a preheated radiant warmer. 2Dry the newborn. 3Check the heart rate. 4Clear the airway. 5Stimulate the newborn by rubbing the back.
Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate.
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? Any time prior to discharge Within 12 hours Within one hour Within 72 hours
Within one hour
The Apgar score is based on which 5 parameters? heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, tone, and color heart rate, breaths per minute, irritability, reflexes, and color heart rate, respiratory effort, temperature, tone, and color
heart rate, muscle tone, reflex irritability, respiratory effort, and color
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 name on the baby's identification bracelet. Check the identification badge of any health care worker before releasing baby from room. Provide a list of approved visitors who came spend time with the infant. Send a family member to accompany the infant when leaving the room.
Check the identification badge of any health care worker before releasing baby from room.
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? "You need to give your newborn a bath everyday." "Place the newborn on the back to sleep and stomach to play." "Newborns can sleep on a couch to allow constant visual monitoring." "Change the newborn's diaper every four hours while awake."
"Place the newborn on the back to sleep and stomach to play."
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 fluid in the scrotal sac." "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 normal male genitalia."
"The opening of his urethra in located on the under surface of the tip of the penis."
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "It is best practice to change the diaper every 2 to 4 hours, even during the night."
"We will fold down the front of her diaper under the umbilical cord until it falls off."
What is the expected range for respirations in a newborn?
30 to 60 breaths per minute
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? The nurse will complete any procedures the infant was not able to have performed while in the hospital. Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. Caregivers can demonstrate competency in caring for the infant and ask questions. The nurse can discuss parenting conflicts with the caregivers to determine which style is best.
Caregivers can demonstrate competency in caring for the infant and ask questions.
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: milia. vernix caseosa. Epstein pearls. oral candidiasis (thrush). SUBMIT ANSWER
Epstein's pearls. Epstein's pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.
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? If the fontanel feels full, then this is normal. This is an abnormal finding and needs to be reported immediately. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. This finding is normal if the pulsation can also be palpated in the posterior fontanel.
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.
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
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.
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? Refreeze any unused milk for later use if it has not been out more that 2 hours. Use any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk.
Use the sealed and chilled milk within 24 hours.
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? two arteries and two veins one artery and two veins three arteries and no veins two arteries and one vein
two arteries and one vein
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is a normal skin finding in a newborn." "It is an indication that the woman has mistreated her newborn." "It is a self-limiting virus that does not require treatment." "It is a sign of a group B streptococcus skin infection. "
"It is a normal skin finding in a newborn."
Assessment of a newborn reveals the following findings: Length, 48 cm; weight, 2900 g; apical pulse, 150 beats/min; respirations, 24 breaths/min; head circumference, 31cm; chest circumference, 32 cm; temperature 97.9°F (36.6°C). After reviewing these findings, the nurse would notify the provider about which one(s)? Select all that apply. You Selected:
respirations (30-60) head circumference (32-37cm) chest (30-26cm) temp (97.7-99.5) HR (110-160) length (44-55cm) weight (2500-4000g)
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Administer the medication. Identify the newborn. Determine the newborn's weight. Assess the newborn for bleeding.
Identify the newborn.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next? Prepare the infant for an exchange transfusion. Draw blood for a metabolic panel. Initiate phototherapy. Obtain a transcutaneous bilirubin level.
Obtain a transcutaneous bilirubin level.