CH.18 MATERNAL NURSING MANAGEMENT OF NEWBORN
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." Explanation: Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy.
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 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." "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."
"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." Explanation: Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, does not help prevent ophthalmia neonatorum, or strengthen the immune system.
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 comfort.
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 1 to 2. 5 to 9. 7 to 10. 12 to 15.
7 to 10. Explanation: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.
The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? Follow the nap and feeding schedule used at home. Be consistently attentive to the infant's basic needs. Allow the infant opportunities to self-soothe. Ensure the caregivers bring blankets and toys from home.
Be consistently attentive to the infant's basic needs. Explanation: To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her needs.
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. The nurse can discuss parenting conflicts with the caregivers to determine which style is best. Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. The nurse will complete any procedures the infant was not able to have performed while in the hospital.
Caregivers can demonstrate competency in caring for the infant and ask questions. Explanation: Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge.
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: oral candidiasis (thrush). Epstein pearls. milia. vernix caseosa.
Epstein pearls. Explanation: Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Oral candidiasis (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.
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 thermoregulation related to heat loss to the environment Altered nutrition less than body requirement related to limited formula intake Altered urinary elimination related to postcircumcision status Ineffective airway clearance related to mucus and secretions
Ineffective airway clearance related to mucus and secretions Explanation: Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.
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. Explanation: The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? No interventions are needed. This will resolve on its own over the next several days. An ice pack should be placed on the edematous scalp. Have the mother massage the scalp twice daily to reduce the swelling. Place a snug cap on the newborn's head to compress the swelling.
No interventions are needed. This will resolve on its own over the next several days. Explanation: This newborn has a caput succedaneum, which is soft tissue swelling that occurs from pressure of the presenting part during labor. No interventions are needed; inform the parents that this should improve over the next several days without treatment.
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 Explanation: Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.
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: potential for respiratory distress. poor oxygenation. cold stress. acrocyanosis.
acrocyanosis. Explanation: Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.
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? Apgar score blood sugar heart rate temperature
blood sugar Explanation: Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).
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, reflexes, and color heart rate, respiratory effort, temperature, tone, and color heart rate, breaths per minute, irritability, tone, and color
heart rate, muscle tone, reflex irritability, respiratory effort, and color Explanation: A newborn can receive an Apgar score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.
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.
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 continual kicking continual crying constriction of blood vessels
lack of subcutaneous fat Explanation: Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? Inform the mother of the results of the hearing test completed on the newborn. Compare the identification bracelets prior to leaving the newborn with the mother. Explain the procedure completed on the newborn to the mother. Determine if it is time for the mother to breastfeed the newborn and assist as needed.
Compare the identification bracelets prior to leaving the newborn with the mother. Explanation: Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed.
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. Explanation: Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.
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? "Your newborn should finish a bottle in less than 15 minutes." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient Explanation: A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.
