Chapter 14: Nursing Care of the Normal Newborn

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Administer aquamephyton. Aquamephyton, or 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.

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

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C) Temperatures of less than 97.7 ° F (36.5° C) or greater than 100 ° F (37.8° C) should be reported to the primary care provider.

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot The calcaneus is the bone of the heel. A heel stick should not be done on the flat part of the foot or heel, but instead on the lateral aspect of the foot, where the fat pads are.

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. Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

A nurse is preparing to administer erythromycin ointment to a 30-minute-old newborn. What will the nurse do first?

Review the health care provider's order. Prior to administering the erythromycin ointment, the nurse will review the order. The nurse would then explain the procedure to the caregivers, apply gloves, and administer the medication in both eyes.

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn. The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly. Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.

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

Which nurse is practicing in a manner to reduce or eliminate pain in a newborn?

The nurse who suggests to the primary care provider to change ordered IM antibiotics to IV. In order to reduce pain in a newborn, the nurse must think about where painful stimuli comes from and try to eliminate it. The nurse who suggests changing the medication route from IM to IV is the one who is demonstrating how to reduce pain in newborns. Sucrose nipples are used for soothing of newborns, not plain water. Changing the time of day for the procedures does not change the amount of pain, nor does doing it before or after feedings.

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 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.

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

Look at the woman's hospital identification badge. Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.

A newborn male has just returned to the mother's room after being circumcised. Which behaviors will concern the nurse?

Being restless and crying If a newborn is in pain, he/she will be crying, restless, have facial grimacing, increased heart rate and increased blood pressure. Bowel movements and urination are expected. Newborns respond to pain and stress by sleeping. An apical pulse rate of 150 is normal for a newborn.

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 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.

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. Hypospadias is contraindicated for circumcision. The circumcision is postponed so that the foreskin can be used to repair the hypospadias. Sucrose water can be given for pain relief in circumcision; however, it would not be given if the procedure is cancelled.

The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure?

Monitor the site for bleeding. Immediately after the procedure, the nurse will monitor the site for bleeding. A petrolatum gauze dressing will be applied to the site before applying a diaper and returning the newborn to the caregivers. An analgesic may be given for pain and the nurse will monitor for infection, but the risk for bleeding is priority immediately following the procedure.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.

There is a family history of hemophilia. The infant is at 33 weeks' gestation. Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness. A fever at birth is not a problem as long as it comes back down to normal shortly after birth. A small penis or a father who was never circumcised are not reasons to delay circumcision.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

Using a bulb syringe, suction the mouth then the nose. A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

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 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.

The nurse is teaching a new mother how to handle and dress her newborn. Which of the following statements from the mother indicates that teaching was effective?

"I should hold my baby close to my body like I'm holding a football." The mother should hold the baby close to her body to provide security. The "football" hold is a convenient method because it provides a free hand with which to perform additional tasks. It is easier to pick up a newborn when he or she is lying on the back (supine) rather than on the stomach (prone). If the infant is on the stomach, the mother should turn him or her over before picking up, to make the process more secure. The diaper should be folded below the cord stump. The mother should also wrap the baby securely in a blanket. This process is known as swaddling and helps many babies feel more secure.

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." 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.

The nurse is teaching infant security to a group of new nurses on a labor and delivery unit. Which characteristic fits the profile of the typical newborn abductor in the United States?

12 to 50 years of age The profile of a newborn abductor in the United States is female, married or in a relationship, and 12 to 50 years of age. These typical abductors also intend to keep the child for their own.

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?

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 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 Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

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. 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.

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress?

If the neonate becomes cold stressed, it will eventually develop respiratory distress. If cold stressed, the infant eventually will develop respiratory distress- O2 requirements rise, even before noting a change in temperature, glucose use increases, acids are released into the bloodstream and surfactant production decreases bringing on metabolic acidosis. Bundling and using a hat will help prevent heat loss by evaporation which can lead to cold stress. It is better if the neonate remains in a flexed position as it will assist with keeping warm. The neonate should stabilize its temperature by 8 hours as long as proper measures are followed.

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. 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.

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?

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.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping. It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean delivery?

Suctioning the newborn's airway. The changes in respiration are the greatest challenge for the newborn. This challenge is even greater in newborns born via a cesarean section. The baby must begin breathing immediately after birth. As soon as the cord is clamped, the infant's lungs become the organs of gas exchange. Excess secretions in the airway can block breathing and, if inhaled, can cause aspiration pneumonia. Maintaining the airway is the nurses priority. Keeping a thermoneutral environment, monitoring for hypoglycemia, and assessing for congenital defects are all important, but not priority.

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. 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 experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns?

Wearing artificial nails while caring for multiple newborns. Artificial nails should not be worn in client care areas, especially in nurseries where there are immunocompromised clients like newborns. The nails are more likely to harbor bacteria than natural nails. The nurse can use waterless hand sanitizer between clients when the hands are not visibly soiled. Gloves should be worn when caring for unbathed newborns. Performing a surgical-type scrub prior to the start of a shift may help reduce the transmission of infections.

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.

respirations head circumference 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.

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." Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.

The nurse is giving discharge teaching to a new mother. Which statement, made by the mother, indicates additional teaching is necessary?

"I will suction my baby's nose then mouth as needed with the bulb syringe." The mouth should be suctioned before the nose is suctioned with the bulb syringe. Newborns sleep an average of 16 to 20 hours a day and generally eat every 2 to 4 hours. The newborn should sleep alone and supine in a crib.

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?

A female in her mid-20s who appears pregnant Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students.

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 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.

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply.

A washcloth Warm tub of water Thermometer 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.

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?

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 preparing to weigh a newborn just admitted to the nursery. Place the steps listed below in the order that the nurse would complete them. Use all options.

Balance the scale. Cover the scale with a warmed cloth. Recalibrate the scale to zero. Place the unclothed newborn in the center of the scale. Newborns are weighed on admission to the nursery or are taken to a digital scale to be weighed and returned to the parent's room. First, the nurse balances the scale if it is not balanced. Then, the nurse places a warmed protective cloth or paper as a barrier on the scale to prevent heat loss by conduction and recalibrates the scale to zero after applying the barrier. Next, the nurse places the unclothed newborn in the center of the scale. The nurse keeps a hand above the newborn for safety.

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

Chlamydia Gonorrhea Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn, which infants contract at birth. The treatment is the use of an antibiotic ophthalmic ointment that is usually applied within the first hour. Trichomonas, syphilis, and candidiasis do not cause ophthalmia neonatorum.

The experienced nurse notes a new graduate administering a hepatitis B vaccination to a newborn. What action, by the new graduate, will cause the experienced nurse to intervene?

Circularly cleaning the site, outward to inward. Hepatitis B is given intramuscularly to newborns. The site will be cleaned in a circular motion from inward to outward to decrease contamination. The other statements are correct for this procedure.

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air. Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply.

It is thinner and more fragile than an adult's Substances are easily absorbed. An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.

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.

Jitteriness Lethargy Seizures 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.

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. 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.

Which technique(s) will the nurse use when administering an intramuscular (IM) injection to a term neonate? Select all that apply.

Stabilizing the needle with the nondominant hand Using a quick darting motion Injecting slowly into the anterolateral thigh The nurse should insert the needle should at a 90-degree angle with the dominant hand while using the nondominant hand to stabilize the needle. The nurse should use a quick darting motion and then slowly inject the medication for even distribution and to minimize the neonate's discomfort. Pulling back to check for blood return is no longer a recommended or necessary process because of the lack of blood vessels in the anterolateral thigh.

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

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

The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate?

"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. The weight loss is a normal finding. There is no need to talk to the health care provider, increase the number of breastfeeding sessions, or switch to formula.

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." 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.

A nurse teaches new parents how to soothe a crying newborn. Which statement, by the parents, indicates to the nurse the teaching was effective?

"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 placing 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?

"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.

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.

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

"It will decrease the risk of bleeding immediately after birth." Vitamin K is necessary for the formation of clotting factors. It is synthesized by normal flora in the gastrointestinal (GI) tract. Because a newborn's GI tract is sterile at birth, the newborn cannot synthesize vitamin K. Newborns are routinely given a vitamin K injection to decrease the risk of hemorrhage. Vitamin K cannot prevent hemorrhage, nor does it prevent infections.

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dl (1.67 mmol/L) Blood glucose levels less than 40 mg/dl (2.22 mmol/L) or 50 mg/dl (2.77 mmol/L), depending on the source of information, is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation.

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." Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy.

The hospital is providing a class on newborn care to a group of parents prior to their discharge with their newborns. Which statement by a parent would indicate that further teaching is needed?

"If our baby turns red in the face and strains to have a stool that means she is constipated." Straining and turning red in the face when having a stool is not indicative of constipation. This is normal behavior. Parents should be comfortable in using a bulb syringe, remember to keep crib rails up at all times, and should not overdress their infants to try to keep them warm.

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." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?

0.5 Each injection for a newborn should be no more than 0.5 mL.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

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. 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 newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?

After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?

Administer the medication into the anterolateral muscle. Vitamin K should be administered into a large muscle such as the anterolateral muscle of the newborn's thigh. The deltoid muscle is not used for intramuscular injections in the newborn. The medication should be given so as not to interrupt breastfeeding. Swelling and irritation at the injection site is a possible adverse reaction and does not necessarily need to be reported to the physician.

Which statement regarding newborn circumcision is accurate?

An advantage of circumcision is a decreased risk of penile cancer. 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.

The charge nurse hears the call, "Shoulder dystocia in room 4." What resources will the charge nurse dispatch to room 4 to assist with this situation? Select all that apply.

Anesthesia Surgeon Pediatrician The resources the charge nurse will call include anesthesia, pediatrician, and surgeon. A social worker may be needed later, but is not needed during the delivery process. The rapid response team is not specific to the needs of this client's situation.

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client?

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.

The health care provider has ordered EMLA cream for an infant scheduled for a circumcision. What nursing action is priority?

Apply the cream one hour before the procedure. If an anesthetic cream, such as EMLA, is to be used for the procedure, it must be applied approximately one hour before the procedure to adequately numb the area. Gathering supplies and positioning will occur prior to the procedure but are not priority. Circumcision is generally a family choice so the nurse does not need to determine whether it is necessary or not.

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 to see the woman' hospital identification badge. 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. 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.

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Baby sleeps with the mother in bed. Evidence that an inadequate home environment assessment was performed as baby is sleeping with the mother. The American Academy of Pediatrics recommends newborns have their own crib as a step toward preventing sudden infant death syndrome. The baby having a changing area, the kitchen has a refrigerator, and the windows are covered with screens indicate that the home environment is adequate to support the needs of a newborn.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?

Be consistently attentive to the infant's basic needs. To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her needs.

An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant?

Before feedings To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Infants are screened even in the absence of symptoms; this is done before feeding to obtain a preprandial measure.

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 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.

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

Bradycardia Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia.

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.

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 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 explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions. Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge.

What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test?

Compare the identification bracelets prior to leaving the newborn with the mother. Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed.

A nursing instructor is conducting a class on the topic of circumcision. The instructor determines the class needs more education when they choose which factor as an advantage for having a circumcision?

Decreases risks of skin dehiscence, adhesions, and urethral fistulas Newborn males who are circumcised are noted to have higher rates of skin dehiscence, adhesions, and urethral fistulas. They are also noted to have fewer STIs, penile cancer, or UTIs.

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply.

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door. The newborn's temperature is low and she needs to be warmed up. Placing a cap on her head and wrapping her in a blanket helps the newborn conserve body heat. Determining the maternal room temperature is important to ensure that the newborn was not chilled while out with the mother, and helps determine the cause of the hypothermia. Lastly, placing the crib away from walls and drafts will help prevent heat loss and maintain a thermoneutral environment. Increasing the nursery temperature is not a good idea since this may overheat this newborn as well as other babies in the nursery.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother. Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns. To prevent injury from hypoglycemia, prevention of hypoglycemia is critical. Breastfeeding mothers are encouraged to begin feedings early and continue on a frequent basis. Bottle-fed newborns require early feedings as well. Thermoregulation can also help maintain a newborn's blood glucose. Doing a heel stick blood glucose is a good idea for a lethargic newborn but will not prevent hypoglycemia from occurring. Glucose water feedings are no longer recommended.

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. 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.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply.

Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn. By preventing hypothermia in a newborn, the chance of hypoglycemia is lessened since cold stress causes a newborn to burn more calories. Feedings should also begin early, with either breast milk or formula. Glucose water does not provide enough glucose for the newborn. Skin-to-skin (kangaroo) care keeps the newborn in a thermoneutral environment.

The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session?

Keep all of the newborn's belongings together in the bassinet. By keeping all the newborn's belongings in the bassinet and not sharing items, the risk of cross-contamination is greatly reduced. Rooming-in, not staying in the nursery, also reduces the likelihood of cross-contamination. Artificial nails are shown to increase infection transmission and should not be worn.

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?

Keep it dry. Until the cord falls off, fold diapers below the level of the umbilical cord, so that when the diaper becomes wet, the cord does not become wet also. Remind the mother to continue to keep the cord dry until it falls off. The nurse should not teach the mother cover the umbilical cord with dry gauze, wash it with soap and water, or apply petroleum jelly to the site.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

The nurse is bathing a newborn for the first time. Place in order how the nurse would perform these tasks during the bathing procedure. Use all options.

Fill a tub with warm water and add a mild soap. Using a soft washcloth, wash the newborn all over. Comb the hair to remove any dried blood. Take the newborn's axillary temperature. Cover the head with a cap, apply a diaper and dress the newborn. Swaddle in a warm blanket and place in an open crib. Thermoregulation is the most important part of bathing a newborn. The nurse will take the newborn's temperature and, once it is stable, the newborn is bathed. Warm water with a mild soap is used, and the entire body is bathed. Any dried blood in the hair or on the head is removed gently with a comb. After the bath is complete, the newborn's axillary temperature is taken and, if it's above 97.7°F (36.5°C), the newborn is dressed, swaddled in a warm blanket and placed in an open crib.

Parents are taking home their second child. They also have a 2-year-old at home. The nurse would anticipate which behavior by these parents?

General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

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 Newborns whose mothers have a positive HBsAg must receive a hepatitis B immunization as well as hepatitis B immune globulin for the prevention of hepatitis B in the newborn. IVIG is not specific for hepatitis B prevention. Hepatitis A vaccination will not prevent hepatitis B in the newborn.

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?

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.

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply.

Place an identification band on both the mother and the newborn immediately after birth, before separating them. When a newborn is born, three to four identical bracelets are prepared and placed on both the mother and the infant with pertinent data such as mother's name, hospital number, date of birth, time of birth, the newborn's gender along with the health care provider for the mother. Thumbprints are not a reliable way to identify a newborn and mother. Nurses compare information on the bands, not in the chart. The nurse would never ask the parents to identify their newborn by appearance since newborns look a lot alike. Lastly, it may be hard to keep the newborn with the parents all the time due to health care provider visits and procedures such as circumcisions.

The nurse is teaching a couple about the pros and cons of circumcision for their infant son. The nurse knows teaching has been effective when the couple can identify which contraindications to circumcision? Select all that apply.

Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection The procedure is contraindicated in neonates who 1) are still in the transition period; 2) are sick or preterm; 3) have a family history of bleeding disorder until the disorder is ruled out in the neonate; 4) have received a diagnosis of a bleeding disorder; 5) have a congenital genitourinary disorder, such as epispadias or hypospadias. The procedure does not necessitate IV access.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply.

Providing the first bath Changing a diaper Performing a heel stick Accucheck Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply.

Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. Do not remove the identification bands until the newborn is discharged from the hospital. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

Rewarm the newborn gradually. A newborn's temperature is typically maintained at 97.7° F to 99.7° F (36.5° C to 37.5° C). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the primary care provider of the newborn's current temperature since it is outside normal parameters.

The nurse is caring for a newborn who is lethargic, apneic, and not eating well, and has an axillary temperature of 36.2ºC. Which might the nurse have a concern about?

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.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother?

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

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?

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.

A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options.

eyes face hair extremities diaper area The parents should wash the newborn, progressing from the cleanest to the dirtiest areas: eyes, rest of face, hair, extremities, trunk, and back. The diaper area is washed last.

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the care provider if the newborn has more than two episodes of diarrhea in one day.

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 participants correctly choose which items will be on matching identification bracelets?

newborn's sex and date and time of birth 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.