Chapter 21: Care of the Normal Newborn

Which newborn assessment finding requires the nurse to take an action? a. Glucose level of 40 mg/dL b. Axillary temperature of 37° C (98.6° F) c. Mild yellow tinge to skin at 32 hours of age d. Mild inflammation of conjunctiva after eye prophylaxis

ANS: A A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose rapidly. A normal temperature for a newborn is 36.5° to 37.5° C (97.7° to 99.5° F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment. PTS: 1 DIF: Cognitive Level: Application REF: 419 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base a reply? a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection. c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly.

ANS: A Crust is a normal part of healing. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site. PTS: 1 DIF: Cognitive Level: Application REF: 427 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is assessing a newborn's circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement? a. Apply pressure to the site. b. Continue to observe for another 30 minutes. c. Apply the diaper tightly over the circumcised area. d. Apply petroleum jelly to the site with a small piece of gauze

ANS: A If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood vessels. A small amount of blood loss may be significant in an infant, who has a small total blood volume. Continuing to observe could mean additional blood loss. Applying the diaper tightly will not stop the bleeding. Petroleum jelly is applied to keep the diaper from sticking to the circumcised area. It will not stop the bleeding. PTS: 1 DIF: Cognitive Level: Application REF: 425 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

In which position should the parents be instructed to place their newborn for sleep? a. On the back b. On the left side c. On the right side d. On the abdomen

ANS: A The American Academy of Pediatrics (AAP) in 2011 recommended that mothers and fathers be taught to place infants on the back for sleep, because this position is associated with the lowest rate of SIDS. The side-lying position is not advised because of the possibility that the infant might roll to the prone position. The newborn should not be placed on the abdomen. PTS: 1 DIF: Cognitive Level: Application REF: 423, 430 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

Which are the reasons for having auditory screening on all newborns in the first month of life? (Select all that apply.) a. Early identification and treatment b. Reassurance for concerned new parents c. To prevent or reduce developmental delay d. To achieve one of the Healthy People 2020 goals

ANS: A, C, D Newborn auditory screening is done to identify hearing loss and begin treatment. Treatment can help to reduce developmental delay. Newborn auditory screening is a Healthy People 2020 goal. New parents are often anxious regarding this test and the impending results; however, it is not a reason for the screening to be performed. PTS: 1 DIF: Cognitive Level: Application REF: 432, 433 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity

Which newborn testing must be performed prior to discharge from the hospital? (Select all that apply.) a. Pulse oximetry b. Hearing c. Guthrie d. Hypothyroidism e. Galactosemia

ANS: A, C, D, E The pulse oximetry test is used to identify potential cardiac anomalies, so it must be done prior to infant discharge. The Guthrie test is another name for the metabolic screening panel test that is done to identify a group of metabolic diseases that would have a significant impact on newborn infants. Included in this test are observations related to thyroid activity, PKU, and galactosemia. A hearing screening test is recommended during the first month of life. PTS: 1 DIF: Cognitive Level: Application REF: 432, 433 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance/Health Screening

The nurse is preparing a newborn for a circumcision. Which prescribed interventions should the nurse implement to alleviate pain? (Select all that apply.) a. Oral sucrose during the procedure b. Bright lights after the procedure c. Adequate stimulation before and after the procedure d. Acetaminophen (Tylenol) postprocedure, as needed e. EMLA cream (eutectic mixture of local anesthetics) before the procedure

ANS: A, D, E Nonpharmacologic pain relief methods during and after the circumcision include pacifiers, oral sucrose, soothing music, recordings of intrauterine sounds, decreased lights, and talking softly to the infant. Acetaminophen may be given throughout the first day for postprocedure pain. EMLA cream (eutectic mixture of local anesthetics) may be applied to anesthetize the skin before the procedure. Bright lights and stimulation would not be methods to reduce circumcision pain. PTS: 1 DIF: Cognitive Level: Application REF: 426 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

Which should the nurse implement to prevent the kidnapping of a newborn from the hospital? a. Restricting the amount of time infants are out of the nursery b. Questioning anyone who is seen walking in the hallways carrying an infant c. Allowing no visitors in the maternity area except those who have identification bracelets d. Instructing the parents to not give the baby to anyone except the nurse assigned that day

ANS: B Infants should be transported in the hallways only in their cribs. Restricting the amount of time infants are out of the nursery will be difficult to monitor and will limit the mother's support system from visiting. Infants need to spend time with the parents to facilitate the bonding process. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit. PTS: 1 DIF: Cognitive Level: Application REF: 423, 424 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem? a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours. b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn. c. Make sure that all emergency exits are accessible to staff and clients on the unit. d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.

ANS: B Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially "family and/or staff or someone representing themselves as such" is more likely to attempt an infant abduction. The unit should be a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members may prevent beginning sibling attachment and cause separation and stress anxiety to the mother and children. PTS: 1 DIF: Cognitive Level: Analysis REF: 423, 424 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment

When an infant's temperature drops from 98.7° to 97.4° F (37° to 36.3° C), the nurse should: a. instruct parents on cold stress. b. determine time and amount of last feeding. c. increase the temperature in the mother's room. d. evaluate infant for the presence of a blood sugar level higher than 50 mg/dL.

ANS: B Temperature instability in the neonate may be caused by a decrease in blood glucose levels. Infants who do not maintain adequate intake will not have adequate energy to maintain temperature; instructing parents on cold stress and increasing the temperature in the room are interventions to maintain a stable temperature but will not correct the underlying problem. A blood sugar level higher than 50 mg/dL is a normal finding. PTS: 1 DIF: Cognitive Level: Application REF: 420 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8° to 37° C (98.2° to 98.6° F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision? a. Consent b. Vitamin K c. Heart rate d. Temperature

ANS: B The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the infant's heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system. PTS: 1 DIF: Cognitive Level: Synthesis REF: 426 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct? a. "Depress the bulb prior to inserting the tip." b. "Suction the nose first and then the mouth." c. "Keep a bulb syringe in the bassinet at all times." d. "Gradually release the pressure on the bulb while withdrawing it."

ANS: B The mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then the nose is suctioned gently and only if necessary. Suctioning is traumatic to the delicate tissues and may cause edema of the nasal passages. The remaining statements are correct. PTS: 1 DIF: Cognitive Level: Application REF: 417 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? a. "The nurse will draw blood to determine if vitamin K is needed." b. "Vitamin K prevents the possibility of bleeding problems in my baby." c. "My baby will receive a shot when the nurse administers the vitamin K." d. "Vitamin K will be administered shortly after birth, generally within the first hour."

ANS: B This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth. PTS: 1 DIF: Cognitive Level: Application REF: 415 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Which nursing action is a priority to prevent infection in the newborn? (Select all that apply.) a. Wearing gloves before touching neonates b. Washing hands before and after handling any neonate c. Washing hands and arms thoroughly at the beginning of the day d. Sharing some equipment that will not transmit infection from one neonate to another

ANS: B, C At the beginning of their shift, nurses wash their hands and arms thoroughly. Throughout the day, handwashing is important before and after touching any infant. Gloves are not necessary unless personal protective equipment is required because of coming in contact with body fluids. To avoid cross-contamination, each infant's supplies are kept separately from those used for other infants. Supplies in drawers or cupboards of each crib unit should be used only for that infant because they are likely to be touched by nurses giving care. Using them for another neonate could result in the transfer of infectious organisms. PTS: 1 DIF: Cognitive Level: Application REF: 424 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse has just completed discharge teaching to parents on newborn bathing. Which statement made by the parents indicates a further need for teaching? (Select all that apply.) a. "We will clean the diaper area last." b. "We will use cotton-tipped swabs to clean the ears." c. "We will use an antibacterial soap during the sponge bath." d. "We can submerge the baby in a tub of water after the cord falls off." e. "We will shampoo the baby's head using a football hold before unwrapping

ANS: B, C Soap is not necessary for the young infant but if used, it should be gentle and nonalkaline to protect the natural acids of the infant's skin. Do not use cotton-tipped swabs in the infant's ears or nose because injury may occur if the baby moves suddenly. Clean the diaper area last. The cord generally falls off in about 10 to 14 days. Some care providers suggest waiting for the cord to fall off before tub bathing. Before fully undressing the baby, use the football position to shampoo the baby's head. PTS: 1 DIF: Cognitive Level: Analysis REF: 431 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

An hour after birth, the nurse assesses a newborn's temperature and notes that it is 36.2° C (97.2° F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurse's next action? a. Take the infant's temperature rectally. b. Ask the father to test the water to determine if it is too hot. c. Delay the bath until the newborn's temperature is above 36.7° C (98° F). d. Explain to the new parents that no soap should be used to cleanse the eyes.

ANS: C A temperature of 36.7° C (98° F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38° to 40° C (100.4° to 104° F). The nurse and not the father needs to determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information. PTS: 1 DIF: Cognitive Level: Application REF: 421 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching? a. "We understand the tests are performed at 24 to 48 hours." b. "We're glad all the tests can be done on one blood sample." c. "We wish the tests would screen for congenital hypothyroidism." d. "We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks."

ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents need further teaching if they say that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing. PTS: 1 DIF: Cognitive Level: Application REF: 433 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

A 38 weeks' gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis? a. Risk for injury related to potential equipment malfunction of radiant warmer b. Altered tissue perfusion related to use of medications during delivery process c. Ineffective airway clearance due to mode of delivery and use of anesthetics d. Risk for ineffective thermoregulation related to gestational age

ANS: C Delivery via cesarean section may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact. PTS: 1 DIF: Cognitive Level: Analysis REF: 417 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care

A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the mother. Which procedure is correct for identifying the newborn? a. Ask the mother to state her name and the name of her infant. b. Call out the mother's full name before leaving the infant with her. c. Have the mother read her printed band number and verify that it matches the infant's number. d. Return the infant with no special procedure because the student knows the mother and infant.

ANS: C The mother and infant should have identifying arm bands with matching numbers. The other actions do not adequately verify the identities of mother and infant. PTS: 1 DIF: Cognitive Level: Application REF: 423 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

What should the nurse teach to parents about using a bulb syringe? a. Use it only once a day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the mouth before suctioning the nose.

ANS: C The syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth should be suctioned first to prevent aspiration. PTS: 1 DIF: Cognitive Level: Application REF: 417 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which principle is important in providing and teaching cord care? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth.

ANS: D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth. Cord care is done to prevent infection and aid in the drying of the cord. No agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days. PTS: 1 DIF: Cognitive Level: Understanding REF: 422 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which is the purpose of state-required newborn screening? a. Keep the state records updated. b. Document the number of births. c. Allow for accurate statistical information. d. Recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with some common newborn disorders. Keeping state records and documenting the number of births are not the purposes of newborn screening. The number of births is not indicated by the newborn screening test. PTS: 1 DIF: Cognitive Level: Understanding REF: 432, 433 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn? a. Deltoid muscle b. Gluteal muscles c. Rectus femoris muscle d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections. PTS: 1 DIF: Cognitive Level: Understanding REF: 416 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

An infant's temperature is recorded at 36° C (96.8° F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.

ANS: D This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR, but this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia. PTS: 1 DIF: Cognitive Level: Application REF: 420 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities