Nursing Care of the Newborn (Level 1)

What are the five areas that are assessed in the Apgar score?

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

When is the umbilical cord removed?

The cord clamp is removed when the cord stump is dry, usually at 24 hours.

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include? A schedule for teaching infant care A demonstration and explanation of infant care A discussion of mothering skills presented in a nonthreatening manner Emotional support and that will foster dependence on the nurse's expertise

A demonstration and explanation of infant care Teaching the mother by example is a nonthreatening approach that allows her to proceed at her own pace. Learning does not occur on a schedule; questions must be answered as they arise. New mothers need demonstration of appropriate mothering skills, not just a discussion. Although emotional support is required, the plan should encourage independent caregiving.

Respiratory distress syndrome (RDS) develops in a neonate born at 33 weeks' gestation 6 hours after birth. What would the nurse's assessment of the newborn at this time reveal? High-pitched cry Intercostal retractions Respirations of 30 breaths/min Heart rate of 140 beats/min

Intercostal retractions Intercostal retractions are a classic sign of respiratory distress in the newborn. A high-pitched cry is associated with neurologic impairment, not respiratory distress. The lowest respiratory rate of a healthy, resting newborn is 35 breaths/min. With RDS the rate increases, not decreases. Heart rate of 140 beats/min is within expected limits.

The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? The tongue is securely on top of the nipple. The mouth covers most of the areolar surface. Loud sucking sounds are heard during the 15 minutes spent at each breast. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.

The mouth covers most of the areolar surface. Effective attachment involves covering most of the areolar surface of the breast with the newborn's mouth; effective attachment helps compress the milk glands. The nipple must be on top of the newborn's tongue. Loud sucking sounds indicate inadequate attachment. The newborn should suckle for a longer period; the newborn may be sucking only on the nipple.

What ointment is put on a newborns eyes to prevent Chlamydia?

prophylactic antibiotic ointment

What is Meconium?

A dark green substance forming the first feces of a newborn infant. Meconium is passed usually during the first several days of life, and it has no relationship to the pathological condition of diarrhea. Passage of meconium is desirable in the newborn because it indicates patency of the colon and a perforate anus.

A client asks the nurse what advantage breastfeeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? Amino acids Gamma-globulins Essential electrolytes Complex carbohydrates

Gamma-globulins The antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? Cerebral palsy Neonatal syphilis Fetal alcohol syndrome Opioid drug withdrawal

Opioid drug withdrawal These adaptations indicate opioid drug withdrawal; the infant should be monitored for further withdrawal signs during the first 24 hours after birth. Signs of cerebral palsy usually manifest later in infancy. A low-grade fever and copious serosanguineous discharge from the nose are signs of syphilis. Growth deficiencies in length, weight, and head circumference are associated with fetal alcohol syndrome, as are certain facial abnormalities.

What is the Moro reflex?

This is the Moro reflex, which indicates an intact nervous system. The Moro reflex has no relationship to hunger. The Moro reflex disappears after the third month of life; if it persists, a neurologic disturbance may be present. This reflex is an involuntary response to environmental stimuli.

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute? Color Heart rate Respirations Reflex irritability

Color Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color. This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points. https://eaq.elsevier.com/Resources/EAQ_QA/QB-3sk7/Q-9sui-wz6woumh/rihyTable17-1-9780323066617-27.pdf

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss? An allergy to formula A hypoglycemic response Ineffective feeding techniques Excretion of accumulated excess fluids

Excretion of accumulated excess fluids Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask to the client at 2 L/min Readjusting placement of the fetal monitor on the client's abdomen

Helping the client change her position Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because it increases placental perfusion. Although the client should be kept informed of the fetus's condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min . Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority.

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do? Instruct the mother about formula feeding. Explain to the mother that these beliefs are wrong. Provide the mother with books indicating that the milk does not sour. Encourage the mother to take an antianxiety drug while continuing breastfeeding.

Instruct the mother about formula feeding. The nurse should teach the mother how to formula feed, because cultural beliefs are deeply ingrained and it is unlikely at this time that the nurse will change the client's mind. Explaining to the mother that these beliefs are wrong is a judgmental response that does not take into consideration the client's beliefs or feelings. It is not therapeutic to contradict the client, especially when the alternative to breastfeeding will not harm the mother or infant. Providing the mother with books indicating that the milk does not sour is a judgmental response that does not recognize the client's beliefs or feelings. This is not therapeutic. Antianxiety medications are contraindicated in breastfeeding women.

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? Deltoid muscle Rectus femoris Vastus lateralis Gluteus maximus

Vastus lateralis The vastus lateralis is the most appropriate muscle for a newborn's intramuscular injection because it is well developed and there is little danger of nerve injury. The deltoid muscle is too small for a newborn's intramuscular injection. The rectus femoris muscle is not used; it is not as large as the vastus lateralis in a newborn. The sciatic nerve in the newborn is near the outer aspect of the gluteus maximus and might be injured if this site were used for an injection.

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of: Breast milk ingestion Inadequate fluid intake Immaturity of the vascular system Breakdown of fetal red blood cells

Breakdown of fetal red blood cells Physiological jaundice is caused by an increased bilirubin level, a result of the breakdown of fetal red blood cells, which the immature liver cannot conjugate rapidly enough for excretion; this occurs on the second or third day of life. Breast milk jaundice does not occur until the fifth or sixth postpartum day; it is believed to be caused by a factor in the breast milk that inhibits conjugation of bilirubin. Inadequate fluid intake is evidenced by a decreased urinary output and depressed fontanels. Mottling in the newborn is related to an immature vascular system.

A client expresses a desire to breastfeed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breastfeed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request? By telling the client that this is unnecessary because the infant is being fed by gavage By discouraging the client because of the time and effort it will take to pump her breasts By instructing the client that breast milk is inadequate because it does not contain the necessary nutrients By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired

By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired The infant may be fed with breast milk by means of gavage, and the pumping will stimulate milk production that should be adequate when the infant is ready to breastfeed. Until that time, the infant may dry breastfeed after pumping or lie close to the mother's breast for nippling as long as the infant can tolerate it. If the infant is being fed by means of gavage, the mother's breasts may be pumped and the breast milk used for gavage feedings. Time cost and effort are insufficient reasons for the nurse to discourage breastfeeding. Breast milk provides adequate nutrition, protects the infant from necrotizing enterocolitis, and provides antibodies.

A postpartum client is changing her female newborn's diaper, sees what appears to be red-tinged mucus on the diaper, and calls the nursing station for assistance. What nursing intervention is necessary? Notifying the pediatrician Collecting and sending a sample to the lab Monitoring diapers to see whether this continues Explaining that this is a normal reaction to the mother's hormones

Explaining that this is a normal reaction to the mother's hormones Secretion of red-tinged mucus by a newborn, called pseudomenstruation, is the result of prenatal influence by some of mother's hormones. It should last no longer than a few weeks. It is not necessary to call the physician, because this is a normal reaction to the mother's hormones. Monitoring diapers is not necessary, and no sample needs to be collected.

A nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? Flaring nares Acrocyanosis (bluish or purple coloring of the hands and feet caused by slow circulation) Heartbeat of 140 beats/min Respirations of 40 breaths/min

Flaring nares Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the newborn.

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight? Document the findings. Place him in a heated crib. Delay starting oral feedings. Perform serial glucose readings.

Perform serial glucose readings. A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia because maternal glucose is no longer available. The nurse should do more than document the findings; the health care provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.

Phenylketonuria (PKU) testing is performed on a newborn. The nurse plans to explain to the mother the purpose of this screening test. What does this test reveal? Whether the infant is positive for PKU Whether the mother is a carrier of PKU The mother's risk for later development of PKU The infant's risk for development of PKU later in life

Whether the infant is positive for PKU The major purpose of this screening test is to determine whether the infant has phenylketonuria (PKU), which can be detected after the infant has started feedings. Determining whether the mother is a carrier for PKU is not the objective of the test for PKU. Epidemiological information is a purpose of genetic screening; in this instance the most important determination is whether the infant has PKU. Risk for later development of the disorder is not the purpose of PKU testing; it is to determine whether the neonate has the disorder.

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds? Calf muscles Popliteal area Back of the thigh Lower portion of the abdomen

Back of the thigh With DDH there are extra skinfolds on the affected thigh, a result of the displacement of the head of the femur in the acetabulum. There are no extra folds in the calf muscles, popliteal area, or lower part of the abdomen in DDH.

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that: Becomes ecchymotic Crosses the suture line Increases after several hours Is tender in the surrounding area

Crosses the suture line Scalp edema that crosses the suture line is the sign that differentiates between these two conditions; with caput succedaneum the swelling crosses the suture line, whereas it does not in cephalhematoma. Bruising may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will have to be observed for signs of increased intracranial pressure. Pain is not associated with either condition.

A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant: Cannot use shivering to produce heat Cannot break down glycogen to glucose Has a limited supply of brown fat available to provide heat Has a limited amount of pituitary hormones with which to control internal heat

Has a limited supply of brown fat available to provide heat Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown of glycogen into glucose does not supply body heat. Pituitary hormones do not regulate body heat.

What is most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? Duration of cry Respiratory distress Frequency of voiding Decreased temperature

Respiratory distress Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. The temperature of the preterm infant is expected to decrease because of immature thermoregulation.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? Contact precautions are necessary. It occurs during sexual intercourse. It can be acquired during a vaginal birth. Protection is provided by way of maternal immunity.

It can be acquired during a vaginal birth. Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit. Although contact precautions are necessary, herpes infection can occur during sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing process.

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented? Stork bites Forceps marks Mongolian spots Ecchymotic areas

Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.

A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture? Big toe Foot pad Inner sole Outer heel

Outer heel The outer heel is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? Has several firm stools daily Voids six or more times a day Spits out a pacifier when offered Awakens to feed about every four hours

Voids six or more times a day The presence of at least six to eight wet diapers each day indicates sufficient breast milk intake. Several firm stools daily may indicate an inadequate amount of fluid ingestion; the stools of breastfeeding neonates should be soft to loose. Spitting out a pacifier is not an indication of adequate milk consumption; some infants need extra sucking stimulation. Awakening to feed every 4 hours is not a reliable indicator of adequate breast milk intake; sleep patterns vary.

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from: Chlamydia and gonorrhea Syphilis and toxoplasmosis Rubella and retrolental fibroplasia Cytomegalovirus and varicella zoster

Chlamydia and gonorrhea The antibiotic ointment is administered prophylactically to prevent the development of ophthalmia neonatorum, which may be contracted during a vaginal birth to a mother with gonorrhea, Chlamydia, or both infections. Syphilis and toxoplasmosis are contracted by the fetus in utero, not during birth. Rubella is contracted by the fetus in utero. The term "retrolental fibroplasia" has been replaced by the term "retinopathy of prematurity." It is a complex disorder that affects the retinal vessels of preterm infants, causing blindness. Cytomegalovirus and varicella zoster are contracted by the fetus in utero during various stages of pregnancy, not during birth.

After her baby's birth a client wishes to begin breastfeeding. How can the nurse assist the client at this time? Giving the infant a bottle first to evaluate the sucking reflex Positioning the infant to grasp the nipple to express colostrum Leaving the infant and parents alone to promote attachment behaviors Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex Stimulating the rooting reflex effectively encourages the newborn to turn toward the breast in preparation for suckling. Giving the neonate a bottle may interfere with the infant's learning to accept the breast. For milk to be expressed the infant must grasp the entire areola, which contains the secretory ducts. At first the mother should be supervised to help ensure a successful experience.

What is the Apgar score used for?

A measure of the physical condition of a newborn infant. It is obtained by adding points (2, 1, or 0) for heart rate, respiratory effort, muscle tone, response to stimulation, and skin coloration; a score of ten represents the best possible condition.

A newborn has just begun to breastfeed. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse intervene? Tell the client to use the other breast and continue breastfeeding. Delay the feeding to allow more time for the infant to recover from the birthing process. Contact the lactation consultant to help the client learn a more successful breastfeeding technique. Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula.

Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula (an abnormal connection (fistula) between the esophagus and the trachea). Choking, frothy secretions, and episodes of cyanosis are signs of a tracheoesophageal fistula. Oral feedings must be stopped until further evaluation can be accomplished. Continued intake of fluids may result in aspiration. Rest is not the concern. There are no data to indicate that the mother is using inadequate breastfeeding techniques.

What characteristic that may be a potential nutrition problem should the nurse identify in a preterm neonate? Inadequate sucking reflex Diminished metabolic rate Rapid digestion of formula Increased absorption of nutrients

Inadequate sucking reflex The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting. The metabolic rate is increased because of fatigue and growth needs. The digestive process is slow, especially in regard to the ability to digest lipids. Absorption of nutrients is decreased because the gastrointestinal tract is immature.

A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate? Spina bifida Imperforate anus Tracheoesophageal fistula Intrauterine growth restriction (IUGR)

Intrauterine growth restriction (IUGR) Oligohydramnios is associated with IUGR; risk factors for IUGR include inadequate maternal nutrition and other high-risk conditions such as diabetes and preeclampsia. Spina bifida does not affect amniotic fluid volume; it is associated with an increased alpha-fetoprotein level. Imperforate anus does not affect amniotic fluid volume. Tracheoesophageal fistula is often associated with polyhydramnios, which is excessive amniotic fluid.

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: Oxidization of fatty acids Shivering when chilled Metabolism of brown fat Increased muscular activity

Metabolism of brown fat Metabolism of brown fat releases energy and increases heat production in the newborn. Fatty acids are byproducts of the breakdown of brown fat. Shivering is the mechanism of heat production for an adult, not for a newborn. Increased muscular activity will not be successful unless there is an abundance of brown fat.

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant? Clamping the cord a second time Obtaining heel blood to test the glucose level Starting an intravenous infusion of glucose in water Instilling an ophthalmic antibiotic to prevent an eye infection

Obtaining heel blood to test the glucose level Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; it should not be damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined.

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of: Early rooming-in Taking-in behaviors Taking-hold behaviors Parent-child attachment

Parent-child attachment There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychologic behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychologic behavior described by Rubin that occurs after the third postpartum day.

Why do we administer vitamin K intramuscularly to a newborn immediately after birth?

Promote the synthesis of prothrombin. Vitamin K stores are almost absent in the newborn because the intestinal flora that produce this vitamin are not present; vitamin K is an essential precursor of prothrombin, which is part of the clotting mechanism.

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery? Stimulating crying Administering oxygen Putting a moist saline dressing on the cord stump Providing for suctioning of the oropharynx as the head emerges

Providing for suctioning of the oropharynx as the head emerges The color of the amniotic fluid is indicative of meconium staining; the practitioner must therefore prepare for the potential fetal aspiration of meconium. The newborn should not be stimulated to cry until the airway has been cleared of meconium. Oxygen is administered only after a patent airway is established and if needed. Putting a moist saline dressing on the cord stump is unnecessary because there is no indication that umbilical cord blood or a transfusion is needed.

After being shown to the parents, a preterm male newborn weighing 3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit. What should the nurse's plan for parental visits include? Taking them to visit their son as soon as possible Securing a prescription for them to be allowed to visit their son Determining whether their son's condition is satisfactory before taking them to see him Discouraging them from being involved with their son until his prognosis is established

Taking them to visit their son as soon as possible The development of attachment between parents and infant is an important psychological goal and should be facilitated. The decision to visit is the nurse's responsibility and does not require a practitioner's permission. It is important for parents to develop a relationship with the ill newborn even if the prognosis is unfavorable.

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? Covering the trunk to prevent hypothermia Using shields on the eyes to protect them from the light Massaging vitamin E oil into the skin to minimize drying Turning after each feeding to reduce exposure of each surface area

Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed

The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that: These areas usually are normal and will fade within the first year. Color changes represent transient mottling that occurs when the baby is cold. These are characteristic of the harlequin color change that occurs when the newborn lies on the side. Discolorations are probably bruises requiring observation of the infant for the development of jaundice.

These areas usually are normal and will fade within the first year. Areas of deep-blue coloring on the skin, often seen on the lower back and buttocks, are called Mongolian spots. Mongolian spots are a variation within the norm and disappear in the first year. Mottling caused by cold covers the entire body. The harlequin color change is not purple or blue and involves an entire half of the body. In this newborn these are expected findings; if the baby were light skinned, the possibility of bruises should be investigated.

A male newborn has been exposed to HIV in utero. Which assessment supports the diagnosis of HIV infection in the newborn? Delay in temperature regulation Continued bleeding after circumcision Hypoglycemia within the first day of birth Thrush that does not respond readily to treatment

Thrush that does not respond readily to treatment Thrush, an oral infection caused by Candida albicans, is an opportunistic infection that may be indicative of HIV infection. A delay in temperature regulation is more frequently associated with immaturity of the hypothalamus. Bleeding after a circumcision is associated with a bleeding disorder such as hemophilia. Hypoglycemia is usually associated with the infant of a diabetic mother.

An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse assess this newborn? Facial paralysis Cephalhematoma Brachial plexus injury Spinal cord syndrome

Brachial plexus injury Brachial plexus paralysis (Erb-Duchenne palsy) is the most common injury associated with dystocia related to a shoulder presentation; it is caused by pressure and traction on the brachial plexus during the birth process. The newborn's face is not involved with a shoulder presentation. Cephalhematoma is a soft-tissue injury of the head and is not related to shoulder dystocia. Spinal cord syndrome is associated with a breech presentation and is not related to shoulder dystocia.

How should the nurse assess a newborn's grasp reflex? By putting direct pressure along the sole of the newborn's foot By jarring the crib and watch the movement of the newborn's hands By pressing the examining fingers against the palms of the newborn's hands By holding the body upright and allowing the newborn's feet to touch a surface

By pressing the examining fingers against the palms of the newborn's hands Pressing the examiner's fingers against the palms should elicit the grasp reflex of the newborn's hands. Putting direct pressure along the sole of the newborn's foot will cause the toes to hyperextend with dorsiflexion of the big toe (Babinski reflex). Jarring the crib will elicit symmetric abduction and extension of the arms with the thumb and forefingers forming a C, followed by adduction of the arms and finally a return of the arms to a relaxed position (Moro reflex). Holding the body upright and allowing the newborn's feet to touch a surface will elicit alternating flexion and extension of the feet that simulates walking (stepping reflex).

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? Stimulating crying Suctioning the airway Using an Ambu bag with oxygen support Placing the infant in the reverse Trendelenburg position

Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties? Receding jaw Brain damage Tongue thrust Nasal congestio

Tongue thrust Tongue extrusion, a reflex response that occurs when the tip of the tongue is touched, is characteristic of infants with Down syndrome and interferes with feeding; this reflex disappears around 4 months of age. A receding jaw does not interfere with suckling. Down syndrome is caused by a chromosomal defect, not brain damage; the feeding problem is related to the chromosomal defect. Nasal congestion is not a characteristic associated with newborns with Down syndrome.

After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed? Monitoring of cardiac status Assessment of neurological reflexes Ensuring increased caloric intake and fluids Administration of respiratory support and observation

Administration of respiratory support and observation The Silverman-Anderson score is an index of neonatal respiratory distress. A Silverman-Anderson score of 6 does not reflect cardiac function, neurological status, or caloric need. From the internet - Score 10 = Severe respiratory distress Score ≥ 7 = Impending respiratory failure Score 0 = No respiratory distress

A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to: Assess protein metabolism. Reveal potential retardation. Detect chromosomal damage. Identify thyroid insufficiency.

Assess protein metabolism. Phenylalanine is an essential amino acid necessary for growth that may be absent in infants with PKU; testing is performed in all neonates born in the United States. Untreated PKU can lead to retardation; the test will not identify retardation. PKU is a genetic, not a chromosomal, disorder. Testing to identify thyroid insufficiency is performed at the same time as PKU testing, but thyroid deficiency is a problem related to a hormone deficiency, not to PKU.

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds: "It's a fungal infection called thrush." "It's unexpected, and it's called milia." "It's expected, and it's called vernix caseosa." "It's a group of capillaries called telangiectatic nevi."

"It's expected, and it's called vernix caseosa." Vernix caseosa, a cheeselike substance that protects the skin, is secreted by the fetus's skin toward the end of pregnancy. Thrush is an oral fungal infection caused by Candida albicans; usually it is acquired during the birth process. Antifungal medications are required to treat thrush. Milia are distended tiny sweat (eccrine) glands that look like whiteheads on the infant's nose; they disappear without special care. Telangiectatic nevi (stork bites, capillary hemangiomas) are pinkish-red, easily blanched spots that may appear on the upper eyelids, nose, upper lip, lower occiput, and nape of the neck; they have no clinical significance and fade between the first and second years of age.

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect? HIV infection Chlamydia trachomatis infection Retinopathy of prematurity (retrolental fibroplasia) A reaction to the ophthalmic antibiotic instilled after birth

Chlamydia trachomatis infection Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.

A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. With what condition are these signs associated? Hypervolemia Hypoglycemia Hypercalcemia Hypothyroidism

Hypoglycemia SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. These are not signs of hypervolemia. Hypervolemia is usually the result of excessive intravenous infusion. It is unlikely that a full-term SGA infant will need IV supplementation. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.

A newborn male is circumcised. What postcircumcision care does the mother propose that alerts the nurse that she requires additional teaching? "I'll need to change his diapers a lot more often." "I need to call the doctor if there's a lot of bleeding." "I'll be sure to give him a tub bath tomorrow." "I need to apply petrolatum gauze to his penis with each diaper change."

"I'll be sure to give him a tub bath tomorrow." The newborn should not be submerged in a tub. The penis should be gently cleaned with clear, warm water; in addition, sponge baths are given until the cord stump detaches. The diaper should be changed frequently to prevent irritation by urine. There should be minimal bleeding; excessive bleeding requires immediate attention. Petrolatum gauze keeps the diaper from adhering to the surgical site.

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond? "Take another look. They seem fine to me." "It's all right. Most babies have crossed eyes." "This is expected. Your baby is trying to focus." "You're right. I'll contact your health care provider."

"This is expected. Your baby is trying to focus." Newborns' eye movements are uncoordinated, and the eyes may appear crossed as they try to focus. As the eye muscles mature, the apparent strabismus disappears. Stating that the baby's eyes seem fine discounts the mother's concern and is demeaning. Although it is true that the baby's eyes are crossed, the mother should be given an explanation for the apparent strabismus. Telling the mother that she is right and that the health care provider must be contacted is misinformation that will increase the mother's anxiety.

After birth, while inspecting her newborn, a mother notices a discharge from the nipples of her infant's breasts. She asks why this is happening. How should the nurse respond? "It's an effect of your own hormones." "It's caused by Monilia contracted during birth." "There may be a congenital hormonal imbalance." "You had a uterine infection during the pregnancy."

"It's an effect of your own hormones." Some maternal oxytocin crosses the placenta and induces the secretion of fluids that have accumulated in the fetal breasts (sometimes called "witch's milk"). Monilia infection usually manifests as white adherent patches in the oral mucosa (thrush). A congenital hormonal imbalance is uncommon and usually undetectable in the newborn period. Evidence of infection would not appear so soon after birth.

A nurse gives a nasogastric feeding to a preterm male infant. As the mother watches, she asks, "Would it hurt my baby to suck on a pacifier during the feeding?" How should the nurse respond? "There's no real benefit in using a pacifier. Also, there's a relationship between using a pacifier and the development of buck teeth." "If you want, he can suck on a pacifier now, but he may have problems later when he starts to suck from the breast or bottle" "It's difficult to determine the color of his lips while he's sucking on a pacifier. We'd rather wait until he's a little older." "Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings."

"Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings." The pacifier may satisfy nonnutritive sucking needs and stimulate flow of saliva and digestive juices. Protruding ("buck") teeth are associated with thumb sucking. Sucking on a pacifier promotes adaptation later to the breast or bottle; it does not hamper it. There is no evidence that a preterm infant's care is jeopardized by nonnutritive sucking.

An infant has surgery for repair of a myelomeningocele (defect of the spine). For which early sign of impending hydrocephalus should the nurse monitor the infant? Frequent crying Bulging fontanels Change in vital signs Difficulty with feeding

Bulging fontanels After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the first signs.

A nurse in the birthing room gives an injection of vitamin K to a newborn. The vitamin K is prescribed because it: Prolongs prothrombin time Improves absorption of biliary salts Promotes formation of clotting factors in the liver Replaces bacteria that are absent in the intestinal tract

Promotes formation of clotting factors in the liver Because the newborn's gastrointestinal tract is sterile, the infant does not have the bacteria necessary to synthesize vitamin K; vitamin K stimulates the liver's production of clotting factors. A prolonged prothrombin time indicates the potential for clotting problems in the newborn. Vitamin K has no relation to the absorption of biliary salts. The vitamin K does not replace the necessary bacteria; these will develop once oral feedings are established.

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first? Report this finding. Administer nasal oxygen. Lower the head of the bassinette. Remove secretions from the pharynx.

Remove secretions from the pharynx. An increase in mucus production is expected during the second reactive period; mucus should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinette may help secretions drain, the newborn cannot remove secretions that block respirations.

The nurse identifies a swelling on the scalp when assessing a newborn. What assessment finding indicates a cephalohematoma? Unusually wide suture line Ecchymotic area over the affected eye Diffuse discoloration over the entire scalp Swelling confined to the area over one skull bone

Swelling confined to the area over one skull bone A cephalohematoma, or collection of blood between the periosteum and skull bone, is confined to an area over a single cranial bone. Wide suture lines indicate the possibility of hydrocephalus. An ecchymotic area over the affected eye may be the result of a misplaced forceps; it is not characteristic of a cephalohematoma. Skin discoloration may be present for a number of reasons, such as vacuum extraction or forceps trauma.

While inspecting her newborn a mother asks the nurse why her baby has flat feet. Before responding, what information should the nurse consider? Flat feet are common in children, requiring them to wear orthotic shoes. The newborn's feet are so small that it is difficult to determine whether there is an arch. Flat feet are associated with deformities of the bones of the feet such as clubfoot. The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat.

The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat. Newborns and infants have fat pads where the arch should be; the arch develops when the toddler begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant. Flat feet are not associated with foot deformity.