Exam 2 NEWBORN

Tonic neck reflex

"fencing posture" a newborn assumes when supine and turns the head to the side.

The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they:

A. wash the top of the can and can opener with soap and water before opening the can.

Infant's body temperature is greater than 37.5°C (99.5°F).

-Remove infant from radiant warmer. - Dress infant in a tee shirt and wrap in one blanket. - Retake axillary temperature in 1 hour.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae:

. are benign if they disappear within 48 hours of birth

• Physiologic jaundice occurs in

60% of term infants and 80% of preterm infants.

Lauren is a breast-fed, 2-week-old infant who weighed 6 lb, 5 oz at birth. She now weighs 7 lb, 3 oz and appears healthy. The nurse is discussing breast-feeding with Lauren's mother. Lauren's mother says that the baby has been "hungrier than usual" the past several days and wants to nurse more often. The nurse should recommend which of the following? A. Increase frequency of feedings to ensure adequate milk supply. B. Offer Lauren a bottle of formula after breast-feeding. C. Begin feeding Lauren a small amount of rice cereal several times a day. D. Breast-feed every 4 hours, using a pacifier between feedings to keep Lauren content.

A A. Milk production depends on the principle of supply and demand. Increasing the frequency of feedings will increase the demand for milk production. B. Supplemental bottle feedings should be avoided until breast feeding is well established to prevent nipple preference. C. Solid foods are not compatible with the ability of the gastrointestinal tract and nutritional needs of the newborn and should not be introduced before 4 to 6 months. D. Decreasing the frequency of breast-feeding will decrease the demand for milk production and thus decrease the milk supply for the infant.

Keep the infant covered with a blanket. This maintains warmth. Newborns are prone to hypothermia, which can be produced by evaporation during the bathing process.

Cleanse the eyes with plain water. Wash each eye from the inner to the outer canthus by using a clean portion of the washcloth with each swipe. If crusts are present on eyelid margins, apply a moistened washcloth or cotton balls for 1 to 2 minutes before cleansing

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe? ****

D. Multiple gestation and low birth weight

The nurse should include which instructions when teaching a mother about the storage of breast milk?

Milk thawed in the refrigerator can be stored for 24 hours. . Wash hands before expressing breast milk.

. The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a:

Moro reflex.

Infant continues with signs of discomfort after appropriate interventions

a. Reassess possible cause of pain. b. Notify primary caregiver

With regard to hemolytic diseases of the newborn, nurses should be aware that:

he indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

he cremasteric reflex refers to

retraction of testes when chilled.

A frequently used method of determining gestational age is the New Ballard Score. It assesses

six external physical and six neuromuscular signs

A newborn male, estimated to be 39 weeks of gestation, would exhibit:

testes descended into scrotum.

With regard to umbilical cord care, nurses should be aware that:

the stump can easily become infected.

The parent-infant relationship is strengthened through

the use of touch, eye contact, voice, odor, entrainment, biorhythmicity, reciprocity, and synchrony

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

use a rear-facing car seat.

With a fresh washcloth dampened with plain water, cleanse the infant's mouth. Wash inside the lips, cheeks, dorsal surface of the tongue, the roof of the mouth, and all along the upper and lower gum pads. Teach parents to do similar mouth care after feeding the infant. Good oral hygiene removes excess milk that stays on the infant's gums and may encourage bacteria and plaque and lead to tooth decay.

Uncover the infant's upper body, and keep the lower body covered with the blanket. This prevents hypothermia. 16. Cleanse the infant's upper body with warm water and soap. Quickly rinse soap from the infant's hands.Infants frequently put a fist in the mouth, which may lead to soap ingestion if the fists are not rinsed. Cleanse the abdomen around the umbilicus with warm water, and keep the cord dry.Dry the area. Apply a cord care product if required by agency protocol until the area is healed. Umbilical cord care may help the drying process and help to prevent infection.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:

alerts the physician that the infant has a dislocated hip.

Vitamin K is given to the newborn to:

enhance ability of blood to clot.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to:

expect a yellowish exudate to cover the glans after the first 24 hours.

A. Newborn turns head toward stimulus when eliciting rooting reflex.

not normal When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth.

Despite their appearance as term infants, late preterm infants are at increased risk for

respiratory distress, temperature instability, hypoglycemia, apnea, feeding difficulties, and hyperbilirubinemia.

DOCUMENTATION • Temperature of infant before and after warming. Also, documentation of periodic temperature assessments if infant under the warmer for a prolonged period of time. • Length of time under the warmer. • Temperature of infant 1 hour after removing from the warmer • Condition of skin after warming process

yep.

• The neonate's most critical adaptation to extrauterine life is to establish effective respirations.

• Signs of respiratory distress can include nasal flaring, intercostal or subcostal retractions (in-drawing of tissue between the ribs or below the rib cage), or grunting with respirations. • Close monitoring of the infant's vital signs is important for early detection of impending problems. Persistent tachycardia can be associated with anemia, hypovolemia, hyperthermia, or sepsis. Persistent bradycardia can be a sign of a congenital heart block or hypoxemia

DOCUMENTATION

A pain assessment tool, such as NIPS (Neonatal Infant Pain Scale), if available • Time the signs occur • Any occurrences that may be related to the onset of the signs • Specific signs the infant demonstrated • Nonpharmacologic interventions used and the results • Any pharmacologic interventions used and the results • Time the signs decreased • Parent teaching that was needed

Valerie is a newborn delivered at 38 weeks' gestation to first-time parents. The parents are naturally anxious over the health of their newborn. The nurse is discussing the newborn's adjustment to extrauterine life. Valerie passed her first stool 12 hours after delivery. Her stool was dark green and sticky. Valerie's parents are concerned and ask if she is constipated. Which of the following is an appropriate response to the parents' concerns? A. This is a normal newborn's first stool, called meconium. B. The newborn's first stool should be yellowish brown and nonsticky. C. The newborn may have a bowel obstruction. D. The newborn will be observed for signs of infection.

[A] Meconium is the infant's first stool: viscid, sticky; dark greenish brown, almost black; sterile; odorless.

Valerie is a newborn delivered at 38 weeks' gestation to first-time parents. The parents are naturally anxious over the health of their newborn. The nurse is discussing the newborn's adjustment to extrauterine life. Valerie's mother has chosen to breast-feed her infant. In preparation for discharge, Valerie's mother asks the nurse how she will know if her baby is getting enough milk. Which of the following is the most appropriate response? A. Provide a pamphlet about the La Leche League for breast-feeding problems or concerns. B. Suggest supplementation with formula if there is concern with the infant's intake. C. Instruct the parents to call if the infant cries frequently or vomits after a feeding. D. She will know by the presence of 6 to 10 wet diapers and 2 to 3 stools per day since she is breast-fed.

[D] The infant should have 6 to 10 wet diapers per 24 hours. The infant may stool with every feeding but should minimally have three bowel movements per 24 hours. Stools transition from meconium to milk stools by 3 to 5 days of age.

Parents express discomfort or anger concerning the infant's pain.

a. Keep the parents informed on interventions utilized to relieve pain. b. Teach parents techniques they may use to assist the infant. c. Allow parents to verbalize frustration concerning caring for an infant experiencing pain.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:

alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.

The initial assessment of the newborn includes

general appearance, vital signs, weight, head circumference, body length, and a neurologic assessment of reflexes

• Jaundice is considered pathologic if it appears within

-the first 24 hours of life, -if serum bilirubin levels increase by more than 6 mg/dL in 24 hours, -or if serum bilirubin exceeds 15 mg/dL at any time

Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.

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Close observation of the newborn's skin color can lead to early detection of potential problems.

Any pallor, plethora, petechiae, central cyanosis, or jaundice should be noted and described

A. Newborns should be bathed every day, for the bonding as well as the cleaning B. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. C. Only plain warm water can be used to preserve the skin's acid mantle. D. Powders are not recommended because the infant can inhale powder. E. Bathe immediately after feeding while baby is calm and relaxed.

B. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. D. Powders are not recommended because the infant can inhale powder.

The Apgar score permits a rapid assessment of the newborn's transition to extrauterine existence based on five signs that indicate the physiologic state of the neonate:

(1) heart rate, (2) respiratory effort, (3) muscle tone, (4) reflex irritability, (5) generalized skin color

Christine is a newborn delivered at 42 weeks' gestation, weighing 10 lbs, 2 oz. Delivery for this first-time mother was assisted with vacuum extraction. The nurse is discussing the infant's physical assessment with the parents. Christine's mother has noted a yellowish color to her 3-day-old infant. Laboratory values indicate a bilirubin level of 6 mg/dL. Which of the following measures should be implemented? A. Increase breast-feeding frequency to 10 to 12 times/day. B. Stop breast-feeding; supplement with formula until jaundice resolves. C. Begin phototherapy with a possible exchange transfusion. D. Continue to breast-feed, but alternate formula or glucose water feedings.

(A) Recommendations for prevention and management of early-onset jaundice in breastfed infants are to monitor for early stooling, initiate early and frequent breastfeeding, and discourage the use of glucose water, formula, or water.

Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

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Shampooing the infant's hair a. Wrap the infant in a dry blanket. b. Hold the infant over the wash basin in a "football" hold. The infant can also be left in the crib; gently pick up the head, and support it in one hand. A blanket can be placed under the head to catch the water. c. Lather the scalp with a small amount of mild soap. A soft washcloth may be used to wash the scalp if there is excess soiling. A fine-toothed comb can be used to comb out excess soil from the hair. d. Rinse the scalp thoroughly by pouring water from a small cup over the infant's scalp into the washbasin or by using a washcloth. e. Dry thoroughly with a towel. f. Comb or brush the infant's hair gently

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Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI?

. Paroxetine The absolute risk of any congenital abnormality associated with citalopram use is small. The absolute risk of any congenital abnormality associated with fluoxetine use is small. The absolute risk of any congenital abnormality associated with sertraline use is small. The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly.

UNEXPECTED OUTCOMES AND NURSING INTERVENTIONS: 1. Diaper rash develops. a. Immediately cleanse and thoroughly dry area after each voiding and stooling. b. Expose the area to warm air and filtered sunlight. 2. Skin becomes very dry, cracked, and peeling. a. Limit bathing to two to three times per week, and use plain water. b. Avoid the use of lotions and products with perfumes or chemicals. 3. Infant experiences cradle cap. a. Shampoo the head daily, and allow shampoo or mineral oil to remain on the scalp until crusts are softened. b. Thoroughly rinse scalp of all soap. c. Use a fine-toothed comb or soft brush to remove loosened crusts gently from the strands of hair. 4. Redness or drainage is present around the umbilical site. a. Keep the area clean and dry. b. Keep a diaper folded below the umbilical site to prevent irritation and to expose the area to the air. c. Report to the health care provider for additional treatment if needed. 5. Infant's temperature falls below 36.8°C (98°F). a. Wrap the infant in an extra blanket and place a cap on the head. b. Reassess the temperature in 30 minutes. c. If the temperature remains low, warm according to agency protocol, such as with use of a radiant warmer. 6. Parents are unable to explain and demonstrate proper bath procedure. a. Establish rapport and allow parents to verbalize concerns. b. Reassess teaching techniques and learning levels. c. Assess for unmet needs the parents have that may prevent learning. d. Assess for cultural differences. Build on parents' cultural practices by reinforcing the positive and promoting change only if a practice is harmful.

.DOCUMENTATION • Record before and after bath temperatures on the graphic sheet. • Describe skin condition. • Record parent teaching and response

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.

9 The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color since he exhibits acrocyanosis.

Lauren is a breast-fed, 2-week-old infant who weighed 6 lb, 5 oz at birth. She now weighs 7 lb, 3 oz and appears healthy. The nurse is discussing breast-feeding with Lauren's mother. Lauren's mother says sometimes it is difficult to stimulate the let-down reflex. Which of the following is the most appropriate recommendation? A. Apply warm compresses before feedings. B. Avoid touching breasts or nipples before feedings. C. Wear a well-fitting nursing bra 24 hours a day. D. Feed Lauren in a quiet place, using the same feeding position every time.

A A. The application of warm, moist compresses to the breasts a few minutes before breast-feeding can stimulate the let-down reflex. B. Gentle stroking from the top of the breast to the nipple will stimulate let-down reflex. C. Although a well-fitting nursing bra is necessary for extra support during nursing, this will not stimulate the let-down reflex. D. The let-down reflex is a psychosomatic response that best occurs when the mother is relaxed. The feeding position, however, should be varied and does not influence the let-down reflex.

Christine is a newborn delivered at 42 weeks' gestation, weighing 10 lb, 2 oz. Delivery for this first-time mother was assisted with vacuum extraction. The nurse is discussing the infant's physical assessment with the parents. On examination of the infant, the nurse notes a sharply demarcated swelling over the parietal bones. The occipital and frontal bones are not affected. The neck does not appear edematous and is soft to the touch. The infant is awake and breast-feeding well. What is the most probable cause of the swelling? A. Cephalhematoma B. Subgaleal hemorrhage C. Caput succedaneum D. Hydrocephalus

A cephalhematoma- is formed when blood vessels rupture during labor or birth to produce bleeding into the area between the bone and its periosteum. The injury occurs most often with primiparous women and is often associated with forceps delivery and vacuum extraction. The boundaries of the cephalhematoma are sharply demarcated and do not extend beyond the limits of the bones, usually the parietals.

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct?

A common practice among Mexican women is los dos. This refers to combining breastfeeding and commercial infant formula. It is based on the belief that by combining the two feeding methods, the mother and infant receive the benefits of breastfeeding along with the additional vitamins from formula. Among the Muslim culture, breastfeeding for 24 months is customary. Muslim women may choose to bottle-feed formula or expressed breast milk while in the hospital. Latino women born in the United States are less likely to breastfeed. East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best for the new mother. The descriptor hot has nothing to do with the temperature or spiciness of the food.

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active B. Acrocyanosis C. Harlequin color sign D. Weight loss representing 5% of the newborn's birth weight

A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.

Which of these statements indicate the effect of breastfeeding on the family or society at large A. Breastfeeding requires fewer supplies and less cumbersome equipment. B. Breastfeeding saves families money. C. Breastfeeding costs employers in terms of time lost from work. D. Breastfeeding benefits the environment. E. Breastfeeding results in reduced annual health care costs.

A. Breastfeeding requires fewer supplies and less cumbersome equipment. B. Breastfeeding saves families money. D. Breastfeeding benefits the environment. E. Breastfeeding results in reduced annual health care costs.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. A. Lubricate the tip of the tube with sterile water. B. Place infant in supine position. C. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. D. Check placement of the NG tube by aspirating gastric contents. E. Gently insert the NG tube through the mouth or nose.

A. Lubricate the tip of the tube with sterile water. B. Place infant in supine position. C. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. D. Check placement of the NG tube by aspirating gastric contents. E. Gently insert the NG tube through the mouth or nose.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs D. Do not let the infant sleep on his or her back E. Keep a bulb suction available at home.

A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs E. Keep a bulb suction available at home.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to:

A. listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

EXPECTED OUTCOMES (thermoregulation) 1. Infant's temperature will stabilize between 36.5° and 37.5°C (97.5° and 99.5°F) axillary or between 36.5° and 37.6°C (97.7° and 99.7°F) rectally. 2. Infant's skin integrity will remain intact

Assess infant's body temperature according to agency protocol. If a newborn's temperature falls below 36.5° C (97.7°F), oxygen consumption and use of calories are increased. This may lead to cold stress Prewarm the radiant warmer to between 36.5° and 37.5° C (97.7° and 99.5°F). Prewarming will prevent loss of body temperature from conduction . Place the infant in a prone position under the heater. This allows greater surface area to be warmed . Place thermal skin probe on the infant's abdomen and attach with an aluminum heat deflector patch. The aluminum heat deflector will prevent heating the probe and causing a false reading. Rapid warming can cause apneic spells; therefore, warming over a period of 2 to 4 hours is recommended Assess the infant's body temperature every 30 minutes or according to agency protocol. This will reduce the risk of hyperthermia and a too rapid increase in body temperature. As the infant's temperature stabilizes, prewarm blankets. Use of prewarmed blankets prevents heat loss from the infant to the cool blankets through conduction When the infant's temperature reaches 36.7°C (98°F), dress the infant, wrap in prewarmed blankets, and place a dry cap on the infant's head. Place the infant in an open crib. The head is the largest surface area of an infant. A cap would prevent the loss of heat through the head. Recheck axillary temperature in 1 hour. Continued assessment of body temperature is important to prevent cold stress

Which action of a breastfeeding mother indicates the need for further instruction? A. Holds breast with four fingers along bottom and thumb at top. B. Leans forward to bring breast toward the baby. C. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. D. Puts her finger into newborn's mouth before removing breast.

B. Leans forward to bring breast toward the baby.

The nurse is caring for an infant born at 28 weeks of gestation. Which complication could the nurse expect to observe during the course of the neonate's hospitalization? (Select all that apply.) A. Polycythemia B. Respiratory distress syndrome C. Meconium aspiration syndrome D. Periventricular hemorrhage E. Persistent pulmonary hypertension F. Patent ductus arteriosus

B. Respiratory distress syndrome D. Periventricular hemorrhage F. Patent ductus arteriosus (problems of preterm infants) [Polycythemia, meconium aspiration syndrome, and persistent pulmonary hypertension are complications of postmaturity.]

Breast milk storage guidelines for home use for full-term infants are:

Before expressing or pumping breast milk, wash your hands. Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they can also be washed in a dishwasher. If the water supply may not be clean, boil containers after washing. Plastic bags designed specifically for breast milk storage can be used for short-term storage (<72 hours). Write the date of expression on container before storing milk. A waterproof label is best. Store milk in serving sizes of 2 to 4 ounces to prevent waste. Storing breast milk in the refrigerator or freezer with other food items is acceptable. When storing milk in a refrigerator or freezer, place containers in the middle or back of the freezer, not on the door. When filling a storage container that will be frozen, fill only three quarters full, allowing space at the top of the container for expansion. To thaw frozen breast milk, place container in the refrigerator for gradual thawing or under warm, running water for quicker thawing. Never boil or microwave. Milk thawed in the refrigerator can be stored for 24 hours. Thawed breast milk should never be refrozen. Shake milk container before feeding baby and test the temperature of the milk on the inner aspect of your wrist. Any unused milk left in the bottle after feeding is discarded.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of life and that breastfeeding be continued as complementary foods are introduced.

Breastfeeding should continue for 1 year and thereafter as desired by the mother and her infant. • Human breast milk is species-specific and is the recommended form of infant nutrition. It provides immunologic protection against many infections and diseases

Cleanse the external ears with plain water and a twisted end of the washcloth. Teach parents not to attempt to clean the internal ear with cotton-tipped applicators. Cleaning the internal ear with cotton-tipped applicators may cause injury

Cleanse the face and neck with plain water. Give special attention to areas behind the ears and creases in the neck. A very small amount of soap may be used for soiled creases, and rinse well after washing. Use of plain water on face will prevent irritation of the eyes by soap accidentally running into them. Mild baby soap can be used for the soiled creases

Lauren is a breast-fed, 2-week-old infant who weighed 6 lb, 5 oz at birth. She now weighs 7 lb, 3 oz and appears healthy. The nurse is discussing breast-feeding with Lauren's mother. Which of the following should the nurse recommend for sore nipples? A. Wash nipples with an antimicrobial soap to prevent infection. B. Position infant so that the entire areola is not grasped. C. Express milk manually and bottle-feed infant until nipples heal. D. Vary infant's position at breast; for example, use the "football hold" at times.

D A. Soaps and self-prescribed treatments for sore nipples should be avoided. B. When positioning the infant, the entire areola should be grasped by the infant and different positions should be used. C. Some mothers experience latch-on discomfort for the first few days when a baby starts nursing. Nipple discomfort after this time period is usually due to incorrect positioning of the baby, which can easily be remedied. Bottle feeding is not necessary and should be avoided until breast-feeding is well established to prevent nipple preference. D. Different positions such as the "football hold" should be used to encourage proper positioning of the infant in which the entire areola is grasped.

Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth? A. Direct Coombs': negative B. Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL C. Blood glucose level: 55 mg/dL D. Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive

D. Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive The negative Coombs' indicates absence of antibodies against Rh-positive blood. Hgb is between 15 and 20 g/dL, and Hct is between 43% and 61%. The blood glucose level should be 45 mg/dL or higher. A reactive RPR/VDRL indicates exposure to syphilis while in utero.

Bathing an infant is an excellent time for the nurse to assess the child and to perform parent teaching. Bathing cleanses the skin and provides both sensory and social stimulation. Because of the risk for hypothermia, the infant must be kept covered to the extent possible, and the bath should be completed quickly. A sponge bath is recommended until after the umbilical cord separates, usually within 10 to 14 days. After the site is completely healed, a tub bath can be given. It is adequate to bathe the infant once or twice a week and as needed when the skin is soiled with body secretions

EXPECTED OUTCOMES 1. Parents will demonstrate an ability to safely bathe, handle, and dress the infant safely while maintaining the infant's body temperature

What is the PRIORITY teaching tip the nurse should provide about bottle-feeding

Hold infant semiupright while feeding. The infant may have a stool with each feeding in the first 2 weeks, although this amount may decrease to one or two stools each day Newborns should be fed at least every 3 to 4 hours and should never go longer than 4 hours without feeding until a satisfactory pattern of weight gain is established. Infants should be held and never left alone while feeding. Never prop the bottle. The infant might inhale formula or choke on any that was spit up. Airway is priority. Taking a few sucks and then pausing briefly before continuing to suck again is normal for infants. Some infants take longer to feed than others. Be patient. Keep the baby awake; encouraging sucking may be necessary. Moving the nipple gently in the infant's mouth may stimulate sucking.

Abnormalities of the skeletal system can be congenital, developmental, drug induced, or the result of intrapartum or postnatal factors. Signs of DDH, additional digits or webbing of digits, and any other abnormality should be documented and reported to the primary health care provider

If thermoregulation is not adequately maintained, the newborn may suffer from cold stress, which can affect oxygenation and result in hypoxia, respiratory distress, hypoglycemia, and metabolic acidosis. Radiant warmers may be used to prevent heat loss during assessments and procedures, and they can be used therapeutically if the infant's body temperature has dropped. Newborns are also at risk for hyperthermia because of their inability to perspire. Signs of hyperthermia include flushed or hot skin, lethargy, and poor feeding

Weaning can be mother or infant initiated.

Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants less than 6 months. If the infant is weaned before 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning. Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. Mother-led weaning means that the mother decides which feedings to drop.

IMPLEMENTATION UNEXPECTED OUTCOMES AND NURSING INTERVENTIONS: Clean gloves are to be worn if this is the first newborn bath or if the nurse is to come in contact with body secretions during any bath. Before the first bath, newborns are covered with blood, amniotic fluid, maternal secretions, and vernix. These substances can transmit microorganisms.

Inspect the infant's skin for dryness, peeling, or signs of infection. Care of the skin during and after the bath may need to be altered to prevent infection or the spread of infections. Peeling is common as the skin dries, and many infants are born with peeling skin if they are past their due date. Assess the site of the umbilical cord for redness, drainage, drying, and intactness. If the umbilical cord is still intact, then a sponge bath is indicated. Redness or drainage at the umbilical site may indicate irritation and/or infection. Assess the infant's temperature if at high risk for hypothermia. Do not bathe if temperature is below 36.8°C (98°F) or according to agency protocol. Prepare the wash basin with warm water at about 36.6° to 37.8° C (98°-100°F). The nurse can test water temperature by placing drops on the inside surface of the forearm. Water should feel comfortably warm. Place the infant in a crib or bassinet with sides, and have all supplies within reach.

Assessment of the newborn requires data from the prenatal, intrapartal, and postnatal periods. The primary goal of care in the first moments after birth is to assist the newly born infant to transition to extrauterine life by establishing effective respirations

The immediate assessment of the newborn includes Apgar scoring and a general evaluation of physical status

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:

The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

This infant is macrosomic and at risk for hypoglycemia. Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella-zoster C. Parvovirus B19 D. Rubella

Toxoplasmosis Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

. Cover the upper body with a dry towel or blanket and uncover the lower extremities.

With a fresh washcloth, cleanse the genitalia with plain water. a. For a female infant: (1) Gently retract labia, and wash from front to back toward the anus. Use separate portions of the washcloth for each swipe. (2) Wash the outer portions of the labia and the folds in the groin. b. For a male infant: (1) Wash from the urethra outward and down toward the scrotum. (2) Wash scrotum and folds of the groin. (3) In uncircumcised newborns, the foreskin should not be retracted. c. In a circumcised newborn, circumcision care is done. (1) Assess the area for bleeding and increased edema. If a Plastibell has been used, check to see whether it is still in place. (2) Cleanse the area gently with warm water and cotton gauze or cotton balls. (3) Sterile gauze dressing with sterile petroleum jelly added is placed between the penis and diaper. This dressing should be changed with each diaper change after the first 12 to 24 hours. (4) If a Plastibell was used in the circumcision process, the gauze and petroleum jelly should not be used. Cleanse the anal area with soap, rinse, and dry. This should be done as a last step to prevent contamination of the vaginal area or circumcision area.

Valerie is a newborn delivered at 38 weeks' gestation to first-time parents. The parents are naturally anxious over the health of their newborn. The nurse is discussing the newborn's adjustment to extrauterine life. Valerie's mother expresses concern over her child's Apgar score of 7 and 10. Which of the following statements should the nurse make to the parents? A. An Apgar score of 7 at 1 minute is a poor result. The test should be repeated to confirm the results. B. Apgar scores of 7 and 10 indicate that the infant's physical and neurologic systems are premature. C. The Apgar score indicates the condition of the infant at 1 and 5 minutes based on heart and respiratory rate, muscle tone, reflex, irritability, and color. The scores of 7 and 10 indicate adjustment to extrauterine life. D. The Apgar score measures the infant's response to stimulus. Scores of 7 and 10 indicate that the newborn's first cry was strong and that the initial parental response was good.

[C] This statement indicates to Valerie's parents that she is adapting to extrauterine life.

Concerning congenital abnormalities involving the central nervous system, nurses should be aware that:

a major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury.

Infant's temperature does not stabilize and stays below 36.5°C (97.7°F).

a. Continue to use radiant warmer to reheat. b. Prevent drops in temperature when not under warmer by: (1) Keeping clothing and bedding dry. (2) Double wrapping the infant and putting a cap on the dry head. (3) Using the radiant warmer during procedures and when bathing. (4) Warming objects that come in contact with the infant. (5) Preventing exposure to drafts. c. Assess for complications that may be producing fluctuations in temperature. d. Assess temperature every hour until stabilized. e. Notify the health care provider as this continues; it is a sign of sepsis.

pain: monitor for

a. Facial expression such as frowns, grimaces, and flinching b. Increased pulse rate, respirations, and blood pressure c. High-pitched, tense, harsh crying d. Increased movement of extremities and clenching of the fists a. Facial expression is one of the best indicators of pain in infants. b. Changes in heart rate are a reliable parameter in the identification of acute pain. c. Crying is the newborn's only verbal communication. The sound of the cry with pain is of a different tone from that for hunger, boredom, or restlessness. d. Muscle tension is a response to pain. The infant may attempt to move away from the source of pain.

Nonpharmacologic pain management:

a. Lower the lights if possible, and keep the area quiet. b. Lay the infant supine or sidelying with extremities flexed into the midline of the body. c. Contain the infant by swaddling, holding, use of positioning devices, or parent-infant kangaroo care. d. Provide non-nutritive sucking. e. Provide a pacifier dipped in a sucrose solution Studies show that infants sucking on a pacifier dipped in sucrose cried less and had fewer changes in heart rate.

. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:

abdominal distention, temperature instability, and grossly bloody stools. The infant may display hypotonia, bradycardia, and metabolic acidosis. Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric aspirates, and oliguria are signs of NEC.

The time, color, and character of the infant's first stool should be noted. Failure to pass meconium can indicate bowel obstruction related to conditions such as

an inborn error of metabolism or a congenital disorder.

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is:

breastfeeding. All breastfed infants should be fed on demand. Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also assists the woman to return to her prepregnant weight sooner. Lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

cleanse eyes from inner to outer canthus before administration.

The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should:

encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz.

The circumcision site is assessed for bleeding

every 15 to 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse monitors the infant's urinary output and notes the time and amount of the first voiding after the circumcision.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:

explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.

Before hospital discharge, nurses provide anticipatory guidance for parents regarding the following:

feeding and elimination patterns; positioning and holding; comfort measures; car seat safety; bathing, skin care, umbilical cord care, and nail care; and signs of illness. • All parents should have instruction in infant CPR

The Babinski reflex refers to

flaring of the toes when the sole is stroked.

If the umbilical cord is still intact, the diaper must be folded so that the umbilical cord is exposed to the air to promote drying and prevent irritation

folding diapers: For optimal absorption of urine, the folded area is placed toward the front for a male infant and toward the back for a female infant.. If diaper pins become dull, stick them into a bar of soap. Keeping the infant dry will help prevent hypothermia, assist with odor control, and decrease the risk for infections

With regard to the classification of neonatal bacterial infection, nurses should be aware that:

health care-associated infection can be prevented by effective handwashing; early onset cannot.

At birth most of the circulating antibodies in the newborn are

immunoglobulin (Ig) G antibodies that were transported across the placenta from the maternal circulation. IgG is key to immunity to bacteria and viruses.

When caring for a newborn, the nurse must be alert for signs of cold stress, including:

increased respiratory rate. Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

Nursing care immediately after birth includes

maintaining an open airway, preventing heat loss, and promoting parent-infant interaction

Heat loss in the healthy term newborn may exceed the capacity to produce heat; this can lead to

metabolic and respiratory complications that threaten the newborn's well-being. • Renal dysfunction resulting from physiologic abnormalities can range from the lack of a steady stream of urine to gross anomalies such as hypospadias and exstrophy of the bladder. Enlarged or cystic kidneys can be identified as masses during abdominal palpation. Some kidney anomalies also can be detected by ultrasound examination during pregnancy

All newborns, and preterm newborns especially, are at high risk for infection during the first several months of life. During this period infection is one of the leading causes of

morbidity and mortality

• Serious infection is not tolerated well by the newborn. Events other than infection (i.e., prolonged crying, maternal hypertension, asymptomatic hypoglycemia, hemolytic disease, meconium aspiration syndrome, labor induction with oxytocin, surgery, difficult labor, high altitude, and maternal fever) can cause?

neutrophilia in the newborn

B. Newborn's fingers fan out when palmar reflex checked. C. Newborn forces tongue outward when tongue touched. D. Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E. Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

normal/expected

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should:

prewarm the radiant heat warmer and place the undressed newborn under it.

Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is:

pulmonary stenosis. tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac defect with decreased blood flow. VSD with increased pulmonary blood flow is the most common type of heart defect with a prevalence of 27 per 10,000 births and accounts for about 30% to 35% of all congenital heart defects. Pulmonary stenosis is less common and is a defect that causes obstruction to blood flow out of the heart. Transposition of the great vessels is a complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the heart or great vessels.

• Birth at 37 to 38 weeks is associated with higher incidence of breastfeeding difficulties and respiratory problems such as

respiratory distress syndrome and transient tachypnea of the newborn. These infants are also at increased risk for long-term problems such as learning difficulties

The purpose of phototherapy is

to reduce the level of circulating unconjugated bilirubin or to keep it from increasing Close follow-up is needed for infants who have been treated for hyperbilirubinemia

• The preferred injection site for newborns is the

vastus lateralis muscle

When weighing a newborn, the nurse should:

weigh the newborn at the same time each day for accuracy.

In helping the breastfeeding mother position the baby, nurses should keep in mind that:

whatever the position used, the infant is "belly to belly" with the mother. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The infant inevitably faces the mother, belly to belly. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.