DA: Nursing Care of the Neonate Family
A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse?
"it is normal for the baby to lose 5% to 10% of her weight during the first week due to diuresis"
A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse?
"the stool is normal and called meconium. the baby may pass this for the first day or two"
An instructor is discussing the hepatic system and its role in the blood coagulation of neonates. Which statement by the nursing student requires further teaching?
"the vitamin K injection is not necessary if the mother is breastfeeding"
A client is concerned because her 2-hour-old newborn is sleeping skin-to-skin and will not breastfeed. Which response by the nurse is correct to explain this behavior?
"this is a normal response after birth and may least an hour or two"
The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply.
- "the mother passes IgA through breast milk and this provides additional protection to the newborn" - "the newborn receives IgG antibodies that provide immunity from infection to which the mother has previously developed antibodies"
The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply.
- assess the penis q15 min for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy - assess for urination and document findings - administer pain medication if ordered
The nurse is assessing a 4-hour-old neonate. Which of the following would be expected findings by the nurse? Select all that apply.
- blood glucose of 38 mg/dL - responsive to external stimuli
The nurse is teaching a class on newborn care to new parents. What should be taught to the parents regarding skin characteristics and care for neonates? Select all that apply.
- clean the perineal area with each diaper change - bathe with neutral pH soap - only suction the nose if mucus or secretions are seen - diapers should be folded below the umbilicus until the umbilical stump falls off
The nurse is teaching the parents of a 4-hour-old neonate about safety. What is the most appropriate teaching the nurse should complete at this time? Select all that apply
- discuss abduction prevention and the purpose of ID bands - discuss delayed bathing - discuss breastfeeding position and latching techniques
The nurse is teaching an expectant parent class about sleep/wake states of newborn behavior. Which statement is correct regarding these infant states? Select all that apply.
- during light sleep, you may notice the baby breathing irregularly; this is normal - during the alert state, the baby will be wide awake with little movement - when crying, the baby will be difficult to calm down and feed
The nurse is performing a physical assessment on a 40-week neonate. Which assessment data does the nurse document as normal? Select all that apply.
- equal gluteal folds - breast buds - acrocyanosis of the hands and feet - overriding sutures
The nurse is preparing to administer the hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply.
- insert the needle at a 90-degree angle - ensure consent has been given - administer in vastus lateralis
When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply.
- instant ear recoil - testis in the scrotum - 0^0 square window
The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complications? Select all that apply.
- meconium-stained amniotic fluid - maternal HTN - prolonged labor over 24 hrs
The nurse is teaching a new mother about newborn screening tests. What should the mother be taught regarding the genetic screening tests performed before the newborn's discharge? Select all that apply.
- most states screen for 30 disorders, and the degree of screening varies from state to state - this newborn screen is don through blood sampling - a neonate with PKU cannot be fed breast milk or formula, due to the inability to metabolize phenylalanine
The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply.
- pulmonary vascular resistance decreased as lung function begins - the forman ovale closes but may reopen from significant hypoxia - amniotic fluid remaining in the lungs after birth may inhibit lung expansion
The mother-baby educator is orienting a group of new nurses and discussing the hepatic system. The educator determines the group understands bilirubin production when choosing which statements as correct? Select all that apply.
- the neonate produces more bilirubin after birth due to an increase in RBC production - direct (conjugated) bilirubin is a water-soluble substance - hyperbilirubinemia may occur from immature liver function
A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions that follow in the correct order.
1. dry the neonate 2. place the neonate skin-to-skin 3. obtain apgar scores 4. assess VS
The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation?
axillary temperature of 97.1F
The nurse is assigned four couplets. After assessing each, which newborn should the nurse report to the physician?
a 2-day-old neonate with irregular respirations at 70 per minute
A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss?
absent startle reflex
The nurse performs an assessment on a 34-week neonate born 4 hours ago. Which assessment finding would be indicative of a preterm neonate?
abundant lanugo
A nurse is checking several newborn reflexes on a 2-day-old neonate. Which reflex would require further investigation?
asymmetrical abduction of the arms when the nurse jars the crib
The nurse is performing screening and laboratory tests on an infant 24 hours after delivery. Select the finding from the following options that should be reported to the neonatal provider.
critical congenital screen heart defect screening results
Which nursing action is the most appropriate demonstration of cultural awareness?
delay interventions and perform assessments while the infant is skin-to-skin
The nurse is admitting a neonate who was delivered vaginally via vacuum extraction and notes a dark red area of unilateral swelling on the scalp. What is the priority nursing action?
document the findings
The nurse is caring for a newborn 2 hours following a circumcision. The nurse notes the circumcised area is red, and there are streaks of blood on the diaper. Which nursing action would be the most appropriate?
document the findings
The nurse is performing an assessment on a 1-day-old neonate and notes a red rash with papules around the chest and abdomen. What is the priority action of the nurse?
document the findings
After the birth of a newborn, what is the priority nursing action to prevent cold stress?
dry the neonate thoroughly
The nurse places the newborn on the mother skin-to-skin immediately after birth. What is the most appropriate teaching for the mother at this time?
encourage the mother to initiate breastfeeding and provide support
The nurse is preparing a male infant for circumcision. The mother is concerned about the pain her infant will experience. What is the most appropriate response by the nurse?
explain how pain is managed before and after the procedure, including a penile block, sucrose, and non-nutritive sucking
After the birth of a newborn, which nursing action promotes parent-infant attachment?
limiting visitors until the mother completes the period pf skin-to-skin contact
The nursery nurse is caring for a neonate diagnosed by prenatal ultrasound with polycystic kidney disease. Which assessment would be a priority for this neonate?
monitor UO
A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems?
neonates have limited subcutaneous fat
Which of the following newborns should the nurse assess first?
newborn with Apgar 8/9, and weight of 4,590 grams
The educator is teaching a class of parents about the newborn's risk of infection. Which newborn is at the highest risk of infection?
newborn with circumcision
A day shift nurse gives a report to the night shift nurse on four newborns. Which newborn should be assessed first?
newborn with clear breath sounds and grunting
A nurse is evaluating the reflexes in a large-for-gestational-age (LGA) infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse?
notify the provider
The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate?
preterm infants have less brown fat stores at birth to use for thermoregulation
The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation?
retractions of the chest wall
The nurse receives a call from a mother who has a 4-day-old newborn breastfeeding every 1 to 3 hours. She is concerned the newborn is not receiving enough milk. What evaluation indicates adequate nutrition?
six wet diapers/three yellow stools per day
A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate?
suction the mouth and nose with a bulb syringe
A nurse is assessing a male infant several hours after a circumcision. Which finding would the nurse document as a sign of pain requiring intervention?
sudden high-pitched cry
A mother is concerned about the eye ointment that was administered to her newborn and the eyelid edema. What is the most appropriate teaching for this mother?
the eye ointment prevents eye infections and the edema is a common side effect that will subside
The nurse performs an assessment on a term newborn and finds a heart rate of 180 beats per minute. What data by the nurse is necessary to determine if the heart rate is a sign of distress?
time of birth
The nurse encourages the mother to hold her newborn skin-to-skin shortly after birth. Which of the following is not a reason for skin-to-skin at delivery?
to ensure infant security until identification bands are applied
The nurse is performing the Brazelton Neonatal Behavioral Assessment Scale on a neonate. Which assessment data does the nurse document as appropriate for orientation?
turning the head toward the mother's voice
The mother-baby educator is performing a skill check-off on neonatal heel sticks with a recently hired nurse graduate on orientation. Which method is correct for collecting blood by heel stick?
warm the foot, clean with alcohol, and puncture the side of the heel
The nurse is caring for a 12-hour-old neonate and incorporating measures to prevent heat loss through conduction. What is the priority nursing action?
warming the stethoscope before assessment
A nurse is performing an assessment on a 12-hour-old neonate. Which assessment finding warrants further investigation and should be reported to the physician
yellow coloring of the skin