Prep U ch 18
A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?
yellow sclera
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates
normal progression of behavior
Client expresses concern that her 2 hour old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:
normal progression of behavior
A nurse needs to monitory the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?
on admission to the nursery
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
Breastfeed the infant every 2-3 hours on demand
A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.
"I understand your concern because as many as 50% of babies can develop jaundice.
A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?
Always wash your hands before you pick up or provide care to your newborn
The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase?
Cardiopulmonary
What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?
Cephalohematoma
A nurse is conducting an assessment for a 3 hour old newborn and notes: RR 30 breaths/min, BP 60/40 mmHg, HR 155 beats/min, temp 98.2 F, and neonate is quite alert. What action should the nurse take?
Document the data
While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next?
Document this as pseudo menstruation
The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?
Gently stroke the newborn's cheek.
A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?
No action is need; this is normal.
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?
Place electronic temperature probe in the midaxillary area.
he nurse is teaching discharge instructions to the young parents of a healthy newborn boy whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?
Redness at the base of the umbilical cord
Nurse completed an assessment on a 1 day old newborn. Which findings should the nurse prioritize?
blood sugar 42 mg/dL
The nurse is assessing a 1-month-old male infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski's sign?
Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe
Which factor might result in a decreased supply of breast milk in a postpartum client
Supplemental feedings with formula
During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. what should the nurse explain to the mother?
This is a normal finding
Assisting in the initiation of breast-feeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding?
Within the first 30 minutes after birth
A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this findings as:
caput succedaneum
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
conduction
Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect?
developmental dysplasia of the hip (DDH
The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as:
erythema toxicum.
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?
first 30 to 60 minutes
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:
harlequin sign
Screening for the most common birth defect is required by law in most states. Each nurse should know the law for his/her state and the requirement for screening. The nurse would expect a newborn to be screened for which defect as the most common?
hearing
Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth
hemoglobin 17.5 g/dl
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
hypothermia
Which factors could increase the risk of overheating in a newborn? Select all that apply
limited ability of diaphoresis isolette that is too warm
Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?
physiologic jaundice
The goal of eye prophylaxis is to:
prevent ophthalmia neonatorum.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
Just after birth, a newborn's axillary temperature is 94 F. What action would be most appropriate?
rewarm the newborn gradually
Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?
scalp edema
A nurse working as a member of a genetic counseling tram understands that her careful assessment of which body areas in a newborn may provide important indications for structural genetic disorders?
space between eyes, shape of ears, numbers if fingers and toes
The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?
undescended testes
A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse?
"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes.
A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?
"Wrapping the newborn too tightly can impair breathing."
What is the expected range for respirations in a newborn?
30 to 60 breaths per minute
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
5% to 10% of their birth weight
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn
Client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?
As long as they are well, absolutely. Why don't we give you a dose of pain meds. beforehand so that you will enjoy the visit?
Which assessment by the nurse will best monitor the nutrition and fluid balance in the poster newborn?
Assess for decrease in urinary output
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?
Bathe the baby under a radiant warmer.
A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate?
Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?
Blood Pressure
A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?
Both the mother and infant have identification bands that need to match.
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?
Check the identification badge of any health care worker before releasing baby from room
The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?
Excessive fluid in its lungs, making respiratory adaptation more challenging
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?
Feeding the infant more formula whenever she begins to fuss
The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply
Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly.
A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?
He should wet between 6 to 10 diapers each day.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother.
The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply.
Hepatitis B vaccination Hepatitis B immune globulin
The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?
Hip for dislocation
Which assessment finding indicates to the nurse that a newborn has hip subluxation?
Inability of the right hip to abduct
The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best?
Inform the practitioner and cancel the procedure.
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?
Injecting the medication into the vests lateralis
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?
Instill 0.5% ophthalmic erythromycin
A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?
Instruct the mom to feed every two to three hours.
The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?
Jitteriness and irritability
During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby?
Low-set ears
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh.
The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize?
Move the infant away from the window.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed
No interventions are needed. This will resolve on its own over the next several days
The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse?
Notify the charge nurse, because it represents a possible complication, and document the finding.
A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?
Offer suggestions based on observation to correct positioning or latching
A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?
Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?
Provide a mobile the child can see no matter how he or she is turned.
A nurse is caring for a newborn with transient tachypnea. Nursing interventions should nurse perform while providing supportive care to newborn?
Provide oxygen, ensure warmth, observe respiratory status
Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?
Rewarm the newborn gradually.
nurse is doing admission assessment on a female infant born to a primipara. Which findings would warrant notification of the physician? Select all that apply.
Scaphoid abdomen, head circumference of 38cm
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty.
Which factor might result in a decreased supply of breast milk in a postpartum client?
Supplemental feedings with formula
Nurse assessing 2-hour-old newborn and notes the infant has irregular patterns of breathing rate, depth, rhythm. Best action made by the nurse?
Taking no action because these are normal findings in a newborn
Which of the following is true regarding the newborn's fontanelles?
The anterior fontanelle is diamond shaped and measures about 3.5cm. The posterior fontanelle is triangular shaped and measures 1cm.
A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?
The infant is attempting self-consoling maneuvers.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?
The infant is experiencing moderate difficulty in adjusting to extrauterine life
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?
The opening of his urethra in located on the under surface of the tip of the penis
The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?
There is more fluid present in the lungs at birth after a c-section than after vaginal delivery
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?
Use the sealed and chilled milk within 24 hours.
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?
We will fold down the front of her diaper under the umbilical cord until it falls off
New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?
We'll hold off on feeding him for a while because he might be too full.
On an Apgar evaluation, how is reflex irritability tested?
flicking the soles of the feet and observing the response
A nurse is assessing a newborn for self-regulation. Which of the following would the nurse interpret as indicating self-regulation?
infant moves hand to mouth
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?
it is a normal skin finding in a newborn
When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?
keeping it dry
When assessing the newborn's umbilical cord, what should the nurse expect to find
two smaller arteries and one larger vein
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. Nurse's first action?
using a bulb syringe, suction the mouth then the nose
At what point should the nurse expect a healthy newborn to pass meconium
within 24 hours after birth
In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.
women on antithyroid medications women on antineoplastic medications women using street drugs
A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection?
working inside an isolette as much as possible.
The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect?
yellowish-brown, seedy stool
