Newborn
When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply.
• Genitals • Lanugo
When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching?
"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas."
A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby?
"May I see your identification, please?"
The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best?
"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."
When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching?
"Use talc powders to prevent diaper rash."
Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?
5
What is the best thing the nurse can do to manage pain in a neonate?
Advocate to the physician to use effective treatment methods that cause no pain or less pain.
A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:
At least 24 hours after birth
All of the following are ways the nurse can encourage bonding between the parents and the newborn EXCEPT
Telling the mother that the best way to bond with her baby is to breastfeed
What is the most important thing the nurse can teach the family of a newborn to prevent abduction while the baby is in the hospital?
Check the identification badge of any health care worker before he or she takes the baby from the room.
A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents?
Cover the glans generously with Vaseline.
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?
Epstein's pearls
A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition?
Erythema toxicum.
It is common for a newborn to have one or two erupted teeth (natal teeth) at birth.
False
The AGPAR score is based on which 5 parameters?
Heart rate, muscle tone, reflex irritability, respiratory effort, and color
The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge?
Hep B
Which of the following nursing diagnosis would be highest in priority for a newborn?
Ineffective airway clearance related to obstruction
A very healthy mother delivered Baby Ambika, who had an immediate Apgar score of 10. Ambika has been cradled in a kangaroo hold by both her mother and her father for 45 minutes and her parents feel ready to get cleaned up and let the baby be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? The nurse will
Instill antibiotic 0.5 percent erythromycin or 1 percent tetracycline eye drops, if they are available, or 1 percent silver nitrate if necessary
Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature?
Less than 97.7 °F or greater than 100 °F.
An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as:
Mongolian Spots
A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond?
Pain administration may not be effective during the procedure
The New Ballard scoring system evaluates newborns on which 2 factors?
Physical maturity and neuromuscular maturity
The infant's temperature is 97.2F axillary an hour after birth. Which intervention is the appropriate for the nurse?
Place the infant under a radiant warmer or in a heated isolette.
A newborn weighed 7 lb. 3 oz. at birth. Based on this birth weight, which procedure would be necessary for you to carry out?
Plotting his weight on a gestational age graph
A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation?
Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe?
Right upper abdominal quadrant
Which is the best place to perform a heel stick on a newborn?
The fat pads on the lateral aspects of the foot
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:
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).
What could be considered to be the best practice for the nurse to follow in giving a newborn his or her first bath?
Wash off all traces of blood and massage the vernix into the skin.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as:
acrocyanosis
Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs?
blood pressure
You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period?
blood sugar
How can the nurse be instrumental in preventing hypoglycemia in the newborn? Choose the best answer.
encouraging early and frequent feedings
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?
evaporative
It is common for a newborn to have one or two erupted teeth (natal teeth) at birth.
false
While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as which of the following?
jaundice
The nurse observes tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:
milia
A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This reflex is known as which of the following?
rooting reflex
All of the following are characteristics of an infant abductor EXCEPT
targets a specific infant
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?
the first 6 months
A new mother is alarmed because her newborn has lost 10 ounces in weight since being born 2 days ago. She believes that she has been breastfeeding properly. Which of the following should the nurse mention as likely causes of this phenomenon? (Select all that apply.)
• Absence of salt- and fluid-retaining maternal hormones • The infant's voiding and passing stool • Low calorie content of colostrum
When performing Ortolani's maneuver, which of the following should occur? Select all that apply.
• Attempt to abduct the hips 180 degrees while applying upward pressure. • The newborn should be in a supine position.
When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do?
Take blood, using a heel stick, to check for hypoglycemia.
Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission.
true
Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply.
• Length of 54 cm • Weight of 3,300 grams • Temperature of 37 degrees C
