Prep-U Newborn Ch: 13, 14, 20

The nurse is assessing the Apgar score for a 1-minute-old newborn and notes the following: HR 105 bpm, a pink body with blue feet, a strong cry, sneezing and minimal flexion. Which Apgar score will the nurse document as appropriate for this infant?

8 *The Apgar scoring system assigns points for five categories to determine the condition of the infant at one and five minutes after birth. The categories are heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. The Apgar score for this infant would be 8 points based on: 2 points for heart rate over 100 bpm; 1 point for color of pink body, blue extremities; 2 points for respiratory effort of strong, vigorous cry; 2 points for reflex irritability demonstrated by the sneezing when stimulated; and 1 point for minimal flexion of the extremities.

Which nursing interventions are essential when caring for a newborn with macrosomia born to a mother with diabetes? Select all that apply. A. Keep the newborn NPO. B. Obtain blood glucose reading. C. Obtain IV glucose for potential infusion. D. Assess for respiratory distress. E. Anticipate supplemental oxygen.

B, C, D, E * Newborns of mothers with diabetes require careful observation. Frequent blood glucose checks begin after birth. Administering feeding early maintains the blood glucose level. If the newborn cannot tolerate feedings, obtain IV glucose for infusion. Monitor for respiratory distress and anticipate supplemental oxygen therapy and surfactant therapy.

The nurse is caring for a baby born to a mother with a history of alcohol use disorder. For what characteristics should the nurse observe to determine if the newborn has a fetal alcohol spectrum disorder? Select all that apply. A. reduced ocular growth B. short palpebral fissures C. flattened nasal bridge D. low-set ears E. increased head circumference

A, B, C * The newborn withdrawing from alcohol typically is hyperactive and irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of a fetal alcohol spectrum disorder include low birth weight, small height and head circumference, short palpebral fissures, reduced ocular growth, and a flattened nasal bridge.

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. A. Give hepatitis B immune globulin. B. Obtain consent from the mother. C. Administer hepatitis B vaccination. D. Place the newborn in isolation precaution. E. Bathe the newborn thoroughly.

A, B, C, E * When a mother has a positive test for hepatitis B surface antigen (HBsAg), the newborn is given the hepatitis B vaccine and hepatitis B immune globulin. Consent must be obtained before administering vaccinations. The newborn should be bathed to remove traces of blood and attempt to limit transmission. Standard precaution should be followed.

In which newborn should the nurse suspect hypoglycemia? A. a jittery, irritable newborn with a high-pitched cry B. a newborn with a heart rate of 60 bpm after a prolonged deceleration in utero C. a newborn who weighs 3500 grams and is falling asleep at the breast D. a newborn who did not do skin-to-skin (kangaroo) care with his mother

A. a jittery, irritable newborn with a high-pitched cry * Signs of hypoglycemia include jitteriness, irritability, lethargy, respiratory distress, and a high-pitched cry.

All of the following complications are more likely to develop in a large-for-gestational-age (LGA) newborn as opposed to an appropriate-for-gestational-age (AGA) newborn except: A. polycythemia B. cesarean delivery C. breech presentation D. shoulder dystocia

A. polycythemia * Polycythemia is more likely to occur in a small-for-gestational-age (SGA) newborn as a response to persistent oxygen deprivation. Cesarean delivery, breech presentation, and shoulder dystocia are all more likely to occur in an LGA infant.

Assessment of a newborn reveals the following findings: Length, 48 cm; weight, 2900 g; apical pulse, 150 beats/min; respirations, 24 breaths/min; head circumference, 31cm; chest circumference, 32 cm; temperature 97.9°F (36.6°C). After reviewing these findings, the nurse would notify the provider about which one(s)? Select all that apply. A. length B. weight C. apical pulse D. respirations E. head circumference F. chest circumference G. temperature

D, E * The assessment findings that are outside normal parameters are the respiratory rate and head circumference. The nurse would notify the provider about these findings. The rest of the findings are within acceptable parameters.

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client? A. Apply petroleum gauze to the penis with each diaper change. B. Monitor the amount of bleeding and chart it. C. Position the infant on his side for comfort. D. Administer analgesics for pain on a scheduled basis.

A. Apply petroleum gauze to the penis with each diaper change. * When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? A. "It is a normal skin finding in a newborn." B. "It is a sign of a group B streptococcus skin infection. " C. "It is an indication that the woman has mistreated her newborn." D. "It is a self-limiting virus that does not require treatment."

A. "It is a normal skin finding in a newborn." * This most likely is erythema toxicum, also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment. This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection.

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin? A. Chlamydia trachomatis B. Group B streptococcus (GBS) C. Human immunodeficiency virus (HIV) D. Herpes simplex type 1

A. Chlamydia trachomatis * Ophthalmic erythromycin is routinely provided to the newborn after birth to prevent acquiring a Chlamydia trachomatis or Neisseria gonorrhoeae infection during vaginal birth. IV antibiotics are used to treat a group B streptococcus infection. Antiviral therapy is given to neonates with herpes simplex type 1 and HIV.

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? A. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. B. Harlequin sign noted on left upper outer thigh. C. Mottling noted on left upper outer thigh. D. Birth trauma noted on left upper outer thigh.

A. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. * A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? A. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth B. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth C. Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth D. Two doses of the hepatitis B immunoglobulin within 24 hours of birth

A. Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth * If a mother has hepatitis B (HbsAG) or is suspected of having hepatitis B, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immunoglobulin within 12 hours of birth. The other choices are the wrong dosages and/or times.

Newborns receive an antibiotic in their eyes within the first hour after birth to prevent neonatorum ophthalmia. Which type of bacteria is most likely to cause this condition? A. Neisseria gonorrhoeae B. Escherichia coli C. Trichomonas vaginalis D. group B streptococcus (GBS)

A. Neisseria gonorrhoeae * N. gonorrhoeae and Chlamydia trachomatis are the organisms that cause neonatorum ophthalmia.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply. A. Bradypnea B. Jitteriness C. Lethargy D. Seizures E. Hyperthermia

B, C, D * Signs and symptoms of hypoglycemia in newborns can include jitteriness, lethargy, cyanosis, apnea, high-pitched or weak cry, hypothermia, and poor feeding. Respiratory distress, apnea, seizures, and coma are late signs of hypoglycemia. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur.

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? A. Only people who are known to the staff are permitted in the nursery. B. Keeping the baby in the mother's room at all times is the best approach. C. Both the mother and infant have identification bands that need to match. D. Security questions everyone before permitting them access to the hospital.

C. Both the mother and infant have identification bands that need to match. * Hospitals have an identification banding system where the mother's and the infant's identification bands are to match. Only people with proper hospital identification should be permitted into the nursery. Keeping the baby in the mother's room at all times could be dangerous because the baby could be left unattended, permitting someone an opportunity to abduct the infant. Security does not routinely question everyone before permitting them access to the hospital.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? A. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. B. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. C. Holding and comforting the newborn will not cause the infant to become spoiled. D. Try walking with the newborn around the house then place her back in the crib to let her cry for a while.

C. Holding and comforting the newborn will not cause the infant to become spoiled. * Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? A. Within 12 hours B. Within one hour C. Any time prior to discharge D. Within 72 hours

B. Within one hour * Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. A. A washcloth B. Hexachlorophene soap C. Warm tub of water D. Thermometer E. Talc powder

A, C, D * The initial bath for a newborn is done using warm water, a mild soap (not hexachlorophene, which can be absorbed through the skin), and a thermometer to check the newborn's temperature following the bath. Talc powder is not recommended because of the risk for aspiration.

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? A. Dry the newborn thoroughly. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Wrap the newborn in a blanket.

A. Dry the newborn thoroughly. * Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as do the infant's forehead and nose. What would the nurse do next? A. Obtain a transcutaneous bilirubin level. B. Draw blood for a metabolic panel. C. Prepare the infant for an exchange transfusion. D. Initiate phototherapy.

A. Obtain a transcutaneous bilirubin level. * Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice.

A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? A. The infant remains free of bleeding. B. The infant's jaundice resolves. C. The infant's hemoglobin level increases. D. The infant remains free of infection.

A. The infant remains free of bleeding. * Vitamin K injections are given to ensure that neonates do not hemorrhage while their immature liver increases production of clotting factors.

When assessing the newborn's umbilical cord, what should the nurse expect to find? A. two smaller arteries and one larger vein B. two smaller veins and one larger artery C. one smaller vein and two larger arteries D. one smaller artery and two larger veins

A. two smaller arteries and one larger vein * When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

B. conduction * Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize? A. Notify the health care provider immediately. B. Assess the newborn for signs of respiratory distress. C. Reassure the parents that this is an expected pattern. D. Tell the parents not to worry since his color is fine.

B. Assess the newborn for signs of respiratory distress. * Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? A. drop in pressure in the neonate's chest B. higher oxygen content of the circulating blood C. higher oxygen levels at the respiratory centers of the brain D. precipitous drop in blood pressure

B. higher oxygen content of the circulating blood * The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale.

The nurse is caring for a neonate that is small for gestational age due to intrauterine growth restriction. Which is the most common cause? A. genetic characteristics B. oxygen and nutrient deficiency prior to birth C. mother with diabetes D. chromosomal abnormalities

B. oxygen and nutrient deficiency prior to birth * The most common cause of a small for gestational age neonate is oxygen and nutrition deficiency prior to birth. Though not stated, this broad category includes mothers who smoke, mothers with a poor diet through pregnancy, or a mother with an illness not allowing proper nutrition to be available for the neonate. Genetic characteristics typically do not cause a small-for-gestational-age neonate. Genetic characteristics may result in the infant's height of shorter stature or the neonate's weight lower, but not below the 10th percentile. Although a few chromosomal abnormalities may result in a small-for-gestational-age neonate, these abnormalities are not a common cause of this outcome. A mother with diabetes commonly results in a large-for-gestational-age neonate.

The nurse is caring for a newborn who is lethargic, apneic, and not eating well, and has an axillary temperature of 36.2ºC (97.1°F). Which might the nurse have a concern about? A. jaundice B. sepsis C. respiratory distress D. hypoglycemia

B. sepsis * Lethargy, apnea, feeding difficulty, and low temperature are all symptoms of neonatal sepsis. Yellow-colored skin is a symptom of newborn jaundice. Nasal flaring, retractions, and increased respiratory rate are symptoms of newborn respiratory distress. Lethargy and jitteriness are symptoms of newborn hypoglycemia.

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? A. "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." B. "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." C. "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." D. "Covering the newborn with heavy blankets is the best way to keep your newborn warm."

C. "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." * Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering. They must rely on metabolizing brown fat. Placing a hat on the newborn can assist with thermoregulation. Newborns less than 8 lb (3630 g) still have brown fat. Windows can be problematic due to the potential for convective heat loss. Covering the newborn with heavy blankets is not recommended, because this can place the newborn at risk for sudden infant death syndrome (SIDS).

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? A. "He has normal male genitalia." B. "His testicles have not descended into the scrotal sac." C. "The opening of his urethra in located on the under surface of the tip of the penis." D. "He has fluid in the scrotal sac."

C. "The opening of his urethra in located on the under surface of the tip of the penis." * The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective? A. "We will vigorously rub our baby's back as we play some music." B. "We will place our baby on the belly on a blanket on the floor." C. "We will turn the mobile on that's hanging on our baby's crib." D. "We will hold feedings until our baby stops crying."

C. "We will turn the mobile on that's hanging on our baby's crib." * Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

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? A. "Newborns swaddled frequently may not respond to this comfort measure." B. "It is best if you use the same blanket each time for swaddling." C. "Wrapping the newborn too tightly can impair breathing." D. "The newborn needs to be held after being swaddled."

C. "Wrapping the newborn too tightly can impair breathing." * Swaddling is a useful measure to comfort a fretful newborn. The only identified problem is that the newborn can become too tightly wrapped, leading to respiratory compromise and breathing difficulties. Swaddling reduces the need to be held, there is no risk of the newborn not responding to it after being swaddled in the past, and the parent does not have to use the same blanket every time.

The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame? A. within 1 hour after birth. B. within 24 hours after birth. C. 24 to 72 hours after birth. D. 4 weeks after solid food is first eaten.

C. 24 to 72 hours after birth. * PKU is an inherited disease involving a specific enzyme necessary in the production of amino acids. Without this enzyme, phenylalanine builds up in the blood and can lead to serious consequences, such as brain damage. Phenylketonuria testing measures the amount of phenylalanine present in the blood. The infant must have taken breast milk or formula for an abnormal amount to be present. The blood sample is obtained via a heel stick and is best conducted 2 to 3 days after birth, allowing time for the infant to eat. The main treatment for this condition is life-long dietary restrictions, so it needs to be identified quickly so appropriate care can be started.

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. A birth weight between 2200 and 3000 g is considered small for gestational age. B. A length between 48 and 50 cm plots out at the 95th percentile for length. C. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. D. Normal birth length is usually 52 cm or above for a full-term newborn.

C. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. * Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? A. Complete the hearing test. B. Provide hepatitis B vaccination. C. Administer vitamin K. D. Perform the newborn screening.

C. Administer vitamin K. * Vitamin K is used to promote blood clotting in the newborn and is priority to administer to the newborn. The hearing test, hepatitis B vaccine, and newborn screening should all be completed prior to discharge.

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take? A. Proceed with the discharge. B. Notify the health care provider. C. Assess the bilirubin level. D. Assist the mother to feed the newborn.

C. Assess the bilirubin level. * If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? A. The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). B. The newborn's blood glucose will remain above 50 mg/dl C. The newborn will experience no bleeding episodes lasting more than 5 minutes. D. The newborn will be correctly identified prior to separation from the parents.

C. The newborn will experience no bleeding episodes lasting more than 5 minutes. * Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

One assessment parameter that the LPN/LVN is responsible for is fluid volume loss. It would be important to assess the umbilical cord for any sign of bleeding. What would be important to assess for if the infant has an unusually large cord? A. disintegrating vessels B. a large amount of Wharton's jelly C. a loose clamp D. a dry cord

C. a loose clamp * One potential source of hemorrhage is the clamped umbilical cord. An unusually large cord may have large amounts of Wharton's jelly, which may disintegrate faster than the cord vessels and cause the clamp to become loose. This situation could lead to blood loss from the cord.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A. gastrointestinal and hepatic B. urinary and hematologic C. respiratory and cardiovascular D. neurological and integumentary

C. respiratory and cardiovascular * Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? A. This is an abnormal finding and needs to be reported immediately. B. If the fontanel (fontanelle) feels full, then this is normal. C. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). D. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).

D. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). * Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel (fontanelle). The fontanel (fontanelle) should not be bulging under any circumstance in a newborn.

A nurse removes and discards a newborn's diaper before placing the newborn on the scales for a daily weight. The nurse realizes there are no clean diapers at the scale. The supply closet is located down the hallway. What will the nurse do? A. Go get another pack of diapers from the supply closet to place at the scales. B. Take a diaper from the newborn next in line to be weighed. C. Wrap the newborn in a blanket and carry the newborn to get another diaper. D. Place newborn in the bassinet and cover with blanket while obtaining diapers.

D. Place newborn in the bassinet and cover with blanket while obtaining diapers. * The nurse will cover the newborn to maintain temperature and place the infant in the bassinet while obtaining more diapers. The nurse would not leave to newborn on the scales and walk away, because the newborn could fall off the scale. Current policy prevents the nurse from carrying the newborn while going to the supply closet to obtain more diapers because this is a fall risk or safety issue. Infection control measures dictate that there is no sharing of supplies between newborns.

Which statement is true regarding fetal and newborn senses? A. A newborn cannot experience pain. B. A newborn cannot see until several hours after birth. C. A newborn does not have the ability to discriminate between tastes. D. The rooting reflex is an example that the newborn has a sense of touch. E. A fetus is unable to hear in utero.

D. The rooting reflex is an example that the newborn has a sense of touch. * The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? A. thermoregulatory B. immunological C. integumentary D. cardiopulmonary

D. cardiopulmonary * The newborn undergoes numerous changes in the cardiopulmonary system immediately after birth, such as increased blood flow to the lungs, closure of the patent ductus arteriosus, and closure of the foramen ovale. The newborn takes over gas exchange once the umbilical cord is cut. Immunological, integumentary, and thermoregulatory systems are all important pieces of the nursing assessment; however, cardiopulmonary is the priority.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? A. thick skin with deep lying blood vessels B. enhanced shivering ability C. expanded stores of glucose and glycogen D. limited voluntary muscle activity

D. limited voluntary muscle activity * Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? A. nonshivering thermogenesis B. lack of brown adipose tissue C. sweating and peripheral vasoconstriction D. radiation, convection, and conduction

D. radiation, convection, and conduction * Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.