Chapter 18: Nursing Management of the Newborn (Prep U)

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." 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.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 1 to 2. 12 to 15. 7 to 10. 5 to 9.

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

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? Place child in a radiant warmer. Assess the baby's temperature. Assess for pain source. Check blood glucose.

Check blood glucose. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? Mongolian spots Epstein pearls milia stork bites

Epstein pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein pearls.

When examining a newborn's eyes, the nurse would expect which assessment? follows a light to the midline has a white rather than a red reflex produces tears when he cries follows your finger a full 180 degrees

follows a light to the midline Newborns do not usually follow past the midline until 3 months of age. They do not tear.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Feeding the newborn a bottle Providing the first bath Taking the newborn's crib to the mother's room Changing a diaper Performing a heel stick Accucheck

Providing the first bath Changing a diaper Performing a heel stick Accucheck 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.

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns? Erythema toxicum Heart rate of 152 beats/min Respiratory rate of 40 breaths/min Temperature instability

Temperature instability Temperature instability is one of several signs of possible sepsis in a newborn. Other signs include poor feeding, lethargy, irritability, and hypoglycemia. Late signs of sepsis include apnea and jaundice. A heart rate of 152 beats/min, a respiratory rate of 40 breaths/min, and erythema toxicum are all normal findings.

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 Suction equipment Ophthalmoscope Identification bands Glucose water

Warmer bed Suction equipment Identification bands In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

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? Clean hands with a betadine scrub. Wear clean gloves. Perform a 3-minute surgical-type scrub. Use infection transmission precautions.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

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: stork bites. erythema toxic. harlequin sign. Mongolian spots.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

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? once a day once a week every other day two or three times per week

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? "I will give sponge baths until the umbilical cord falls off." "I can use talc powders to prevent diaper rash." " I will change my baby's diapers frequently." "It is not necessary to give my baby a bath daily."

"I can use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.

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." "You need to give your newborn a bath everyday." "Newborns can sleep on a couch to allow constant visual monitoring."

"Place the newborn on the back to sleep and stomach to play." Newborns should always be placed on their backs to sleep to reduce the risk for SIDS and on their stomach a few times a day to develop neck muscles. Caregivers should change the newborn's diaper when it is soiled, not at timed intervals. Newborns should never be left unattended on high surfaces to prevent injury from falls. Bathing a newborn daily is not recommended as it may dry the skin.

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? Just before discharge home 24 hours after the newborn's first protein feeding When the infant is 48 hours old 36 hours before the infant is discharged home with its parents

24 hours after the newborn's first protein feeding 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.

What is the expected range for respirations in a newborn? 30 to 60 breaths per minute 40 to 80 breaths per minute 20 to 40 breaths per minute 10 to 30 breaths per minute

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 7. 5. 8. 6.

7. The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).

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? Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand.

Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is 0.66 oz to 1 oz (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? Dry the newborn and place it skin-to-skin on mother. Assess the newborn's glucose level. Complete a full head-to-toe assessment. Swaddle the infant and place in the bassinet.

Dry the newborn and place it skin-to-skin on mother. Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

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? Feeding the infant more formula whenever she begins to fuss Swaddling the infant before returning to the crib Gently patting or stroking the infant's back Rocking and talking to the infant

Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

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? HBV immunoglobin Vitamin K Hep B HiB

Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. VItamin K is given soon after birth to reduce the risk of bleeding

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Assess the newborn for bleeding. Administer the medication. Identify the newborn. Determine the newborn's weight.

Identify the newborn. 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.

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? Altered urinary elimination related to postcircumcision status Ineffective thermoregulation related to heat loss to the environment Ineffective airway clearance related to mucus and secretions Altered nutrition less than body requirement related to limited formula intake

Ineffective airway clearance related to mucus and secretions 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 preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Using a 21-gauge needle Injecting at a 45-degree angle Injecting 1cc of medication 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 of medication at a 90-degree angle.

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. Watch for signs of eye irritation. Instill 0.5% ophthalmic erythromycin.

Instill 0.5% ophthalmic erythromycin. 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.

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 sign of a group B streptococcus (GBS) skin infection. It is an indication that the woman has mistreated her newborn. It is a normal skin finding in a newborn. It is a self-limiting virus that does not require treatment.

It is a normal skin finding in a newborn. This rash is most likely is erythema toxicum, also known as newborn rash.

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? Obtain the temperature rectally. Tape electronic thermistor probe to the abdominal skin. Place electronic temperature probe in the midaxillary area. Obtain the temperature orally.

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? Caregivers need to sleep while the baby is sleeping. Newborns usually sleep for 16 or more hours each day. The infant may sleep through the night around 2 months of age. Place the infant on the back when sleeping.

Place the infant on the back when sleeping. It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action? Allowing the mother to cut the cord of the newborn. Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Wrapping the newborn in a towel and placing it on the mother's abdomen.

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

A woman has just given birth vaginally to a newborn. Which action will the nurse do first? Assess an apical heart rate. Determine the rectal temperature. Apply identification bracelets. Suction the mouth and nose.

Suction the mouth and nose. The first priority is to ensure a patent airway by suctioning the newborn's mouth and nose. Before leaving the birthing area, newborn identification procedures are completed, including applying the identification bracelet and possibly footprinting, depending on the agency's policy. An apical heart rate and temperature are checked soon after birth, but do not take priority over ensuring a patent airway.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? Use of mobiles above the crib. Rocking and singing to her infant. Swaddling the infant Holding and cuddling the infant

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

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. Place the newborn on its stomach with the head down and gently pat its back. Suction the mouth and then the nose with a suction catheter. Suction the nose first and then the mouth with a bulb syringe.

Using a bulb syringe, suction the mouth then the nose. A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

The experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns? Wearing gloves while swaddling an unbathed newborn. Washing the hands for 3 minutes at the start of the shift. Wearing artificial nails while caring for multiple newborns. Using hand sanitizer when the hands are not visibly soiled.

Wearing artificial nails while caring for multiple newborns. Artificial nails should not be worn in client care areas, especially in nurseries where there are immunocompromised clients like newborns. The nails are more likely to harbor bacteria than natural nails. The nurse can use waterless hand sanitizer between clients when the hands are not visibly soiled. Gloves should be worn when caring for unbathed newborns. Performing a surgical-type scrub prior to the start of a shift may help reduce the transmission of infections.

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? temperature blood sugar Apgar score heart rate

blood sugar 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).

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 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 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 hold off on feeding him for a while because he might be too full." 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 has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective? The newborn is about to produce sufficient tears. The newborn does not contract ophthalmia neonatorum. The newborn's sclerae do not appear yellow. The newborn's active eye infection resolves.

The newborn does not contract ophthalmia neonatorum. Eye prophylaxis is given to prevent (not treat) ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia. This is unrelated to tear production or jaundice.

Which statement is false regarding bathing the newborn? While bathing the newborn, the nurse should wear gloves. Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face. 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.

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. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply. low-set ears swollen genitals short, creased neck Mongolian spots enlarged fontanels (fontanelles)

swollen genitals short, creased neck Mongolian spots Mongolian spots, swollen genitals in the female newborn, and a short, creased neck are normal findings in a newborn. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Female babies may have swollen genitals as a result of maternal estrogen. The newborn's neck will appear almost nonexistent because it is so short. Creases are usually noted. Enlarged fontanels (fontanelles) are associated with hydrocephaly; congenital hypothyroidism; trisomies 13, 18, and 21; and various bone disorders such as osteogenesis imperfecta. Low-set ears are characteristic of many syndromes and genetic abnormalities such as trisomies 13 and 18 and internal organ abnormalities involving the renal system.

A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching? "Newborns swaddled frequently may not respond to this comfort measure." "The newborn needs to be held after being swaddled." "It is best if you use the same blanket each time for swaddling." "Wrapping the newborn too tightly can impair breathing."

"Wrapping the newborn too tightly can impair breathing." Swaddling is a useful measure to comfort a fretful newborn. The only identified problem is that the newborn can become too tightly wrapped, leading to respiratory compromise and breathing difficulties. Swaddling reduces the need to be held, there is no risk of the newborn not responding to it after being swaddled in the past, and the parent does not have to use the same blanket every time.

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 tonic neck reflex. It signifies handedness." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "Yes, she is afraid you will drop her." "No, it is the blink reflex. It is meant to protect the eyes."

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

On an Apgar evaluation, how is reflex irritability tested? dorsiflexing a foot against pressure resistance tightly flexing the infant's trunk and then releasing it raising the infant's head and letting it fall back flicking the soles of the feet and observing the response

flicking the soles of the feet and observing the response Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

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 place our baby on the belly on a blanket on the floor." "We will hold feedings until our baby stops crying." "We will turn the mobile on that's hanging on our baby's crib." "We will vigorously rub our baby's back as we play some music."

"We will turn the mobile on that's hanging on our baby's crib." 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 or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? 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. Follow the nap and feeding schedule used at home.

Be consistently attentive to the infant's basic needs. 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? 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. 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. 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 Apgar score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color

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

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. Remove the clamp and replace with another one just above the old one. Notify the doctor to come suture the site of the bleeding. 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. 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.

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? Inform the woman she cannot transport the baby. Ask if the client actually sent the woman. Determine which hospital unit the woman works on. Look at the woman's hospital identification badge.

Look at the woman's hospital identification badge. Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.

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 the woman to bring the infant back when the doctor finishes the examination. Ask to see the woman' hospital identification badge. Ask how long the infant will be gone since her next feeding is in 30 minutes. Call the nursery to confirm the doctor does indeed need this infant at this time.

Ask to see the woman' hospital identification badge. The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

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? Cleanse the glans daily with alcohol. Soak the penis daily in warm water. Notify the primary care provider if it appears red and sore. Cover the glans generously with petroleum jelly.

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.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply. Jitteriness Hyperthermia Lethargy Seizures Bradypnea

Jitteriness Lethargy Seizures Signs and symptoms of hypoglycemia in newborns can include jitteriness, lethargy, cyanosis, apnea, high-pitched or weak cry, hypothermia, and poor feeding. Respiratory distress, apnea, seizures, and coma are late signs of hypoglycemia. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur.

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 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." "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." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

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 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. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

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 be taking about 2 oz of formula for every pound of body weight during each feeding." "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."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." 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.

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's blood glucose will remain above 50 mg/dl The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn will be correctly identified prior to separation from the parents.

The newborn will experience no bleeding episodes lasting more than 5 minutes. Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

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? Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area. Expose the newborn's bottom to air several times a day. Place the newborn's buttocks in warm water after each void or stool.

Expose the newborn's bottom to air several times a day. 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.

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? skeletal malformations vision hearing genetic-linked

hearing Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.