PrepU Diabetes

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth Explanation: The healthy newborn should pass meconium within 24 hours of life.

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?

"I can use talc powders to prevent diaper rash." Explanation: Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.

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." Explanation: As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life

The parents of an 8-month-old tell the nurse that they have a fear that the infant will develop sudden infant death syndrome (SIDS). What is the best response by the nurse?

"Infants who die from SIDS are usually 2 to 4 months old, but I understand your concern." Explanation: Infants who die from SIDS are usually 2 to 4 months old, although some deaths have occurred during the first and second week of life. Few infants older than 6 months die from SIDS.

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?

"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 which will gradually disappear and not need any treatment.This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the mother, nor is it caused by a virus or group beta streptococcal infection

A G1 P1 mother asks the nurse "Why is my baby losing weight? He dropped 6 oz from yesterday to today. Is my breast milk not good?" Which answer is the best response to this new mother?

"It is normal for breastfed newborns to lose as much as 7% of birth weight the first 3 days after birth." Explanation: Breastfed newborns may lose up to 3% of birthweight on day 1, 5% of birth weight on day 2, and 7% of birthweight on day 3; a breastfed infant regains birth weight at about 14 days. Babies are born with the ability to suck milk from either a breast or a bottle. Deferring to answer the question will make the mother think something is wrong with her infant when, in fact, weight loss is normal. It will take about 2 weeks to regain weight, rather than months.

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." Explanation: Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, prevent ophthalmia neonatorum, or strengthen the immune system.

A new mother asks the nurse why her newborn must get a vitamin K injection. Which response made by the nurse is best?

"Newborns need vitamin K to prevent hemorrhage. They cannot produce it themselves right after birth because of the lack of normal flora in their intestines." Explanation: Vitamin K is essential for clot formation and hemorrhage prevention. It is synthesized in the gut by normal flora. The newborn's gastrointestinal system is sterile at birth; therefore, the newborn cannot synthesize vitamin K. Vitamin K is not an immunization, nor does it prevent infection.

The pregnant woman with diabetes asks the nurse why her last baby weighed 11 pounds. What is the best response by the nurse?

"The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone." Explanation: Consistently elevated fetal insulin levels cause the distinctive growth pattern. Because maternal glucose levels are elevated and glucose readily crosses the placenta, the fetus responds by increasing insulin production. Because insulin acts as a fetal growth hormone, consistently high levels cause fetal macrosomia, birth weight of greater than 4,500 g. Insulin also causes disproportionate fat buildup to the shoulders and upper body, increasing the risk for shoulder dystocia and birth trauma.

The mother of a 1-day-old newborn calls the nurse alarmed and asks the nurse to hurry to her room because there is something wrong with her baby. The nurse arrives to find the newborn lying on his crib on his side, awake and crying with one side of his body a dark red color and the other side of his body is pale. What would the nurse tell this mother?

"This is a harlequin sign and is a normal finding in newborns. It usually occurs when the infant is crying or when he is lying on his side." Explanation: A common variant in skin color is the harlequin sign, where the blood vessels on one side of the body dilate (causing a dark appearance) and the blood vessels on the other side constrict (causing pallor). This is normal and requires no intervention or notification of the doctor. Telling a mother that the nurse has never seen this finding does not reassure her, although she is told he is OK.

A newborn has been diagnosed with retinopathy of prematurity. The nurse is teaching the parents about this condition. Which statement would the nurse most likely include in the teaching?

"You'll need to schedule follow-up eye examinations with the pediatric ophthalmologist." Explanation: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination. Surgery may or may not be needed. Eye drops are not used. Some children do grow out of it, but it is inappropriate for the nurse to assume that this is the case with this child.

On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that:

breast milk normally comes in on the third or fourth postpartum day. Explanation: Colostrum has been forming since the fourth month of pregnancy; milk forms on the third or fourth postpartum day.

A nurse is working with four new mothers and assessing their ability to breastfeed. For which mother would breastfeeding be appropriate and safe?

A mother who smokes cigarettes Explanation: Cigarette smoking is not a contraindication to breastfeeding but women should be aware some nicotine is carried in breast milk. The milk of mothers who smoke also tends to be lower in protein and may be less in amount. Breastfeeding is contraindicated in all of the other situations listed

A new mother asks the nurse what medications she can and cannot take into her body because it might affect breast milk. What should the nurse respond to this mother's request?

Almost all drugs are excreted to some extent in breast milk. Explanation: Almost any drug may cross into the acinar cells and be secreted in breast milk. As a general rule, the mother should take no drug unless prescribed or approved by her primary care provider while breastfeeding. Halting breastfeeding could impact the mother's ability to continue at a later time.

Which statement regarding newborn circumcision is accurate?

An advantage of circumcision is a decreased risk of penile cancer. Explanation: Advantages of newborn circumcision are decreased risk of penile cancer and decreased risk of sexually transmitted diseases. The AAP states that the health benefits outweigh the risks of newborn circumcision. Research has shown that newborns do experience pain with circumcision.

A woman in scrubs enters a mother's room, while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask the woman to see her hospital identification badge. Explanation: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?

Aspirate the oral and nasal pharynx with a bulb syringe. Explanation: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

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 Explanation: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11. Explanation: The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information.

In caring for the newborn the nurse recognizes that which finding is abnormal and will require immediate attention?

Blood glucose level less than 40 mg per 100 mL of blood Explanation: Blood glucose levels less than 40 mg per 100 mg of blood suggest hypoglycemia in neonates. The normal respiratory rate for infants at rest is 30 to 60 breaths per minute. Heart rate in infants is usually in the range of 110 to 150 bpm. Hemoglobin levels in neonates are normally in the range of 15 to 18 g per 100 mL of blood because they have an increased blood volume.

You are providing care for a 10 lbs. 2 oz. newborn that is three hours old. The infant begins to display signs of hypoglycemia. You do a heel stick to obtain the infants blood glucose level. At which of the following blood glucose levels would you treat the infant for neonatal hypoglycemia?

Blood glucose of 35 mg/dL Explanation: A healthy newborn's blood glucose level is typically between 40 and 60 mg/dL during the first 24 hours following birth. Levels below 40 mg/mL suggest hypoglycemia.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

Cephalhematoma Vernix caseosa is a thick white substance found on a newborn. Erythema toxicum is a newborn rash. Caput succedaneum is molding or edema.

The nurse is preparing to administer a tube feeding to a preterm infant. When checking for residual prior to the feeding, there is a residual of 3 mL. What action should the nurse take?

Call the physician. Explanation: The nurse should report immediately gradually increasing residual and abdominal girth or return of more than 2 mL of undigested formula. These signs indicate feeding intolerance and could herald the onset of necrotizing enterocolitis (NEC).

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 Explanation: 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 arteriousus, 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.

Which type of breast milk is highest in antibodies?

Colostrum Explanation: Colostrum is the first milk that is expressed postpartum. It is thick, yellow milk and is higher in antibodies than any other type of milk.

What intervention can the nurse provide to reduce pain and stress in the preterm infant?

Create minimal stimulation and reduce procedures that cause pain. Explanation: Minimal stimulation is a necessary precaution to minimize pain and stress. The nurse should reduce procedures that cause crying, such as routine suctioning. He or she should avoid painful procedures and disturbances when possible. The nurse should administer narcotics, as ordered, to treat pain when avoidance is not possible. Additionally, he or she should control the noise level in the environment and provide developmental care and positioning.

A nurse is giving a new mother some tips regarding breastfeeding. Which of the following should she mention?

Empty one breast completely before feeding the baby from the other breast Explanation: An important principle for women to learn is milk forms in response to being used. If breasts are completely emptied, they completely fill again. If half emptied, they only half fill, and, after a time, milk production will become insufficient for proper nourishment. Urge women to always place their infant first at the breast at which the infant fed last in the previous feeding, to help ensure each breast is completely emptied at every other feeding. Because it takes less energy for an infant to suck at a bottle, urge parents not to offer bottles of breast milk until 4 to 6 weeks of age, or after the infant is thoroughly accustomed to breastfeeding. Teach women to wash their breasts before beginning with clear water because soap tends to dry and crack nipples. Be certain infants open their mouths wide enough to grasp both the nipple and the areola (the pigmented circle surrounding the nipple) when sucking. This gives them effective sucking action and helps to empty the collecting sinuses completely.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.

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. Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.

Which is true regarding mineral requirements in the newborn?

Infants who are formula-fed should drink an iron-enriched formula for at least 12 months. Explanation: Breast milk contains an adequate amount of iron, and infants who are breastfed do not need to supplement with oral iron. However, infants do not make adult hemoglobin until 3 to 6 months of age; they therefore need iron-enriched formula. The American Academy of Pediatrics recommends iron-enriched formula for at least 1 year. Mothers who are breastfeeding should drink some fluoridated water. Spring water is not enriched with fluoride.

Which of the following instructions should a nurse give to a lactating client about how to break suction during a feeding?

Insert a finger into the corner of the baby's mouth between the gums Explanation: The nurse should instruct the client to insert her finger into the corner of the baby's mouth between the gums to break the suction. The mother should not tug at the nipple, as this might damage the infant's unexposed teeth. Pressing both the cheeks of the infant simultaneously or shifting the infant to the football hold from the cross-cradle hold will not help break the suction.

Which of the following is an advantage of breastfeeding that directly benefits the mother?

It aids in uterine involution. Explanation: One of the advantages of breastfeeding that benefits the mother is that the release of oxytocin from the posterior pituitary gland, which is triggered by breastfeeding, aids in uterine involution. The other advantages listed directly benefit the baby, not the mother.

Breast milk contains all of the following except:

Listeria Explanation: Breast milk contains immunoglobulins (antibodies), lactoferrin (an iron-binding protein), and the enzyme, lysozyme. Listeria is a bacterium that is not found in breast milk.

The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned infant. Which documentation should the nurse provide?

Mongolian spot noted on left upper outer thigh. A 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 the possibly other injuries would be noted.

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

Morphine Explanation: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid narcotic, is given to the client to ease the withdrawal symptoms and also gradually remove narcotics from the system. The other options do not ease withdrawal symptoms.

The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize?

Move the infant away from the window. The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room

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?

Neisseria gonorrhoeae Explanation: N. gonorrhoeae and Chlamydia trachomatis are the organisms that cause neonatorum ophthalmia.

The nurse is providing care for a 10 lb 2 oz. (4536 g) newborn who is 3 hours old. The infant is jittery, cool, has poor tone, and is not eating well. What will the nurse do next?

Obtain a blood glucose level. Explanation: The newborn is displaying symptoms of hypoglycemia and obtaining a blood glucose level will confirm and determine how severe so treatment may be initiated. Determining when the newborn last ate will not help the current status. A rectal temperature is only needed immediately after delivery to assess rectal patency.

The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?

Obtain a transcutaneous bilirubin level. Explanation: 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.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?

Perform a heel stick to obtain a blood sample for testing for glucose level. If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Place the newborn away from drafts and under a blanket. When a newborn becomes cold stressed, they often develop respiratory distress. The newborn's temperature is low, so the first nursing action is to place the newborn in a warmer environment and cover with a blanket to warm the newborn up. The serum glucose is normal so the newborn does not need additional nutrition. The newborn does not have documented hypoxia, so oxygen is not appropriate. Pillows are never used in newborn's beds due to the risk of suffocation

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Explanation: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

The student nurse is performing a Ballard scale on a newborn. The instructor assesses that the student understands methods to check neuromuscular maturity when she gently pulls the newborn's arm in front of and across the top portion of the body until resistance is met and identifies this action as:

Scarf sign. Explanation: Scarf sign is accomplished by gently pulling the newborn's arm in front of and across the top portion of the body until resistance is met as a measure of neuromuscular maturity. Popliteal angle and posture do not require manipulation of the arm. Square window and arm recoil do not require the nurse to move the arm across the chest.

Which nursing actions limit overstimulation of the preterm infant? Select all that apply. Frequently open the isolette portholes. Keep lights low in the nursery. Tap on the isolette before opening the door. Speak softly to the infant. Coordinate nursing care.

Speak softly to the infant. Keep lights low in the nursery. Coordinate nursing care. Explanation: It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions. Tapping and opening the isolette portholes can startle the infant.

A woman has just given birth vaginally to a newborn. Which action will the nurse do first?

Suction the mouth and nose. Explanation: The first priority is to ensure a patent airway by suctioning the newborn's mouth and nose. Before leaving the birthing area, newborn identification procedures are completed, including applying the identification bracelet and possibly footprinting, depending on the agency's policy. An apical heart rate and temperature are checked soon after birth, but do not take priority over ensuring a patent airway.

The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort?

Swaddle and decrease stimulation Explanation: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones.

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy?

The bedside glucometer is not calibrated for newborns. Explanation: The bedside glucometer must be calibrated for newborns to accommodate the high hematocrit concentrations of the newborn. Otherwise, false readings may occur. The other options are not correct—serum blood sugars are not falsely high, too much blood on the test strip will just wipe off, and the newborn is not breaking down glycogen that quickly.

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria?

The bilirubin peaked between days 3 and 5 after birth. Explanation: Physiologic jaundice involves the liver's inability to break down the bilirubin as fast as it is being produced due to the immaturity of the liver. The criteria for physiologic jaundice is that the jaundice occurs after 24 hours of age, it peaks between days 3 and 5 and does not rise more than 5 mg dL/day. Conjugated bilirubin is the water-soluble version of bilirubin and is excreted in feces; it should always be lower than the unconjugated bilirubin.

In doing the Ballard assessment of gestational age, which of the following is done to assess what is called the scarf sign?

The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met. Explanation: Scarf sign (arm pulled gently in front of and across top portion of body until resistance is met) is one of the six categories that determine neuromuscular maturity in a newborn.

The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?

The newborn does not contract opthalmia neonatorum. Explanation: Eye prophylaxis is given to prevent (not treat) opthalmia neonatorium, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia. This is unrelated to tear production or jaundice.

What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.

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. Explanation: After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

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?

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

What is the best way for the nurse to assess the newborn's heartbeat?

auscultating the apical pulse for 60 seconds Explanation: The best way for the nurse to assess the newborn's heart rate is to listen to the apical pulse for a full minute

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice?

bilirubin hyperexcretion Explanation: Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirbuin conjugation or conversion, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is:

caused by his mother's hormones. Explanation: Both male and female newborns may have a milky breast discharge from being under the influence of female hormones in utero.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

nasal flaring Explanation: Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participates correctly choose which items will be on matching identification bracelets?

newborn's sex and date and time of birth Explanation: Information included on the bands is the mother's name, hospital number, care provider's name, newborn's sex, and date and time of birth. The father's name and infant's blood type would not be included on these bracelets which are put on at the time of birth.

When assessing the newborn's umbilical cord, what should the nurse expect to find?

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.


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