Chapter 18: Nursing Management of the Newborn
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? A.) Conductive B.) Convective C.) Evaporative D.) Radiating
Answer C.) Evaporative
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? A.) Rocking and talking to the infant B.) Swaddling the infant before returning to the crib C.) Feeding the infant more formula whenever she begins to fuss D.) Gently patting or stroking the infant's back
Answer C.) Feeding the infant more formula whenever she begins to fuss Rationale: 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 explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program? A.) Caregivers can demonstrate competency in caring for the infant and ask questions. B.) The nurse can discuss parenting conflicts with the caregivers to determine which style is best. C.) Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. D.) The nurse will complete any procedures the infant was not able to have performed while in the hospital.
Answer: A.) Caregivers can demonstrate competency in caring for the infant and ask questions.
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 - Feeding the newborn a bottle - Taking the newborn's crib to the mother's room
Answer: - Providing the first bath - Changing a diaper - Performing a heel stick Accucheck
A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. - Take warm-to-hot showers to encourage milk release. - Feed the newborn in the sitting position only. - Express some milk manually before breastfeeding. - Massage the breasts from the nipple toward the axillary area. - Apply warm compresses to the breasts prior to nursing.
Answer: - Take warm-to-hot showers to encourage milk release. - Express some milk manually before breastfeeding. - Apply warm compresses to the breasts prior to nursing.
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. - Warmer bed - Glucose water - Suction equipment - Identification bands - Ophthalmoscope
Answer: - Warmer bed - Suction equipment - Identification bands Rationale: In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.
A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply. - lanugo - genitals - arm recoil - scarf sign - posture
Answer: - lanugo - genitals Rationale; Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity.
A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. - lethargy - low-pitched cry - cyanosis - skin rashes - jitteriness
Answer: - lethargy - cyanosis - jitteriness
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. - temperature of 38.3° C (101° F) or higher - refuse feeding - abdominal distention - general fussiness - approximately eight wet diapers a day
Answer: - temperature of 38.3° C (101° F) or higher - refuse feeding - abdominal distention
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? A.) Before feedings B.) Only if the infant is jittery C.) Every 8 hours D.) After feedings
Answer: A.) Before feedings
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.
Answer: A.) Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Rationale: 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 mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? A.) Expose the newborn's bottom to air several times a day. B.) Use only baby wipes to cleanse the perianal area. C.) Use products such as talcum powder with each diaper change. D.) Place the newborn's buttocks in warm water after each void or stool.
Answer: A.) Expose the newborn's bottom to air several times a day. Rationale: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? A.) Help the mother provide skin-to-skin (kangaroo) care. B.) Place a second stockinette on the baby's head. C.) Administer a warm bath with temperature slightly higher than usual. D.) Place the infant under a radiant warmer.
Answer: A.) Help the mother provide skin-to-skin (kangaroo) care.
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?' A.) Inspect the clamp to insure that it is tightly closed and applied correctly. B.) Clean the cord with soap and water, as oozing of blood is a common finding. C.) Remove the clamp and replace with another one just above the old one. D.) Notify the doctor to come suture the site of the bleeding.
Answer: A.) Inspect the clamp to insure that it is tightly closed and applied correctly. Rationale: 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.
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? A.) No interventions are needed. This will resolve on its own over the next several days. B.) An ice pack should be placed on the edematous scalp. C.) Have the mother massage the scalp twice daily to reduce the swelling. D.) Place a snug cap on the newborn's head to compress the swelling.
Answer: A.) No interventions are needed. This will resolve on its own over the next several days.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? A.) Toes fan out when sole of foot is stroked. B.) Newborn throws arms outward and flexes knees. C.) Newborn makes stepping motion. D.) Newborn's toes curl over the nurse's finger.
Answer: A.) Toes fan out when sole of foot is stroked. Rationale: The Babinski sign is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? A.) Use the sealed and chilled milk within 24 hours. B.) Use any frozen milk within 6 months of obtaining it. C.) Use microwave ovens to warm the chilled milk. D.) Refreeze any unused milk for later use if it has not been out more that 2 hours.
Answer: A.) Use the sealed and chilled milk within 24 hours.The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.
Which newborn neuromuscular system adaptation would the nurse not expect to find? A.) an extrusion reflex at 9 months of age B.) a Moro reflex at 3 months of age C.) a positive Babinski sign at 2 months of age D.) a plantar grasp reflex at 7 months of age
Answer: A.) an extrusion reflex at 9 months of age Rationale: An extrusion reflex usually disappears around 4 months of age. A positive Babinski sign can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.
Shortly after the birth of a newborn, the parent notices a gray patch across the newborn's buttocks. The parent is immediately concerned that the newborn has been bruised during the birth and asks the nurse about this. The nurse recognizes the patch as a birth mark and explains this to the parent. Which type of birth mark is this most likely to be? A.) congenital dermal melanocytosis (slate gray nevi) B.) cavernous hemangioma C.) infantile (strawberry) hemangioma D.) nevus flammeus
Answer: A.) congenital dermal melanocytosis (slate gray nevi)
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: A.) harlequin sign. B.) stork bites. C.) congenital dermal melanocytosis (slate gray nevi). D.) erythema toxic.
Answer: A.) harlequin sign. Rationale: Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.
After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? A.) two or three times per week B.) once a week C.) once a day D.) every other day
Answer: A.) two or three times per week Rationale: Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.
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? A.) "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." B.) "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." C.) "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." D.) This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."
Answer: B.) "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? A.) "Change the newborn's diaper every four hours while awake." B.) "Place the newborn on the back to sleep and stomach to play." C.) "Newborns can sleep on a couch to allow constant visual monitoring." D.) "You need to give your newborn a bath everyday."
Answer: B.) "Place the newborn on the back to sleep and stomach to play."
The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? A.) Follow the nap and feeding schedule used at home. B.) Be consistently attentive to the infant's basic needs. C.) Allow the infant opportunities to self-soothe. D.) Ensure the caregivers bring blankets and toys from home.
Answer: B.) Be consistently attentive to the infant's basic needs. Rationale: 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.
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? A.) Recommend that the mother pump her breast milk and measure it before feeding. B.) Breastfeed the infant every 2 to 4 hours on demand. C.) Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. D.) Add cereal to the newborn's feedings twice a day.
Answer: B.) Breastfeed the infant every 2 to 4 hours on demand. Rationale: Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is 0.66 oz to 1 oz (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? A.) Inform the mother of the results of the hearing test completed on the newborn. B.) Compare the identification bracelets prior to leaving the newborn with the mother. C.) Explain the procedure completed on the newborn to the mother. D.) Determine if it is time for the mother to breastfeed the newborn and assist as needed.
Answer: B.) Compare the identification bracelets prior to leaving the newborn with the mother. Rationale: 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.
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: A.) oral candidiasis (thrush). B.) Epstein pearls. C.) milia. D.) vernix caseosa.
Answer: B.) Epstein pearls. Rationale: Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Oral candidiasis (thrush) is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.
A woman has just given birth vaginally to a newborn. Which action will the nurse do first? A.) Apply identification bracelets. B.) Suction the mouth and nose. C.) Assess an apical heart rate. D.) Determine the rectal temperature.
Answer: B.) Suction the mouth and nose. Rationale: 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 caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation? A.) Gastroesophageal reflux B.) Sudden infant death syndrome C.) Apnea episodes D.) Sleeping for short intervals
Answer: B.) Sudden infant death syndrome
The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? A.) Perform a 3-minute surgical-type scrub. B.) Wear clean gloves. C.) Use infection transmission precautions. D.) Clean hands with a betadine scrub.
Answer: B.) Wear clean gloves.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe if the infant is in the supine position? A.) lower back B.) abdomen C.) left axilla D.) right great toe
Answer: B.) abdomen Rationale: A thermistor probe is taped to the newborn's abdomen, usually in the right upper quadrant. Some research, however, recommends midline placement. This allows for position changes without having to readjust the probe.
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? A.) Apgar score B.) blood sugar C.) heart rate D.) temperature
Answer: B.) blood sugar
On an Apgar evaluation, how is reflex irritability tested? A.) raising the infant's head and letting it fall back B.) flicking the soles of the feet and observing the response C.) dorsiflexing a foot against pressure resistance D.) tightly flexing the infant's trunk and then releasing it
Answer: B.) flicking the soles of the feet and observing the response Rationale: Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.
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."
Answer: C.) "The opening of his urethra in located on the under surface of the tip of the penis." Rationale: 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 is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters? A.) 28 cm B.) 30 cm C.) 33 cm D.) 37 cm
Answer: C.) 33 cm Rationale: The average chest circumference is 30 to 36 cm (12 to 14 in). It is generally equal to or about 2 to 3 cm less than the head circumference.
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: A.) 1 to 2. B.) 5 to 9. C.) 7 to 10. D.) 12 to 15.
Answer: C.) 7 to 10. Rationale: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.
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.
Answer: C.) Assess the bilirubin level. Rationale: 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 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? A.) Administer an oral dose of vitamin K to the newborn. B.) Assume that the parents refused this medication for their infant. C.) Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. D.) Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.
Answer: C.) Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Rationale: 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.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? A.) Administer the medication. B.) Determine the newborn's weight. C.) Identify the newborn. D.) Assess the newborn for bleeding.
Answer: C.) Identify the newborn.
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? A.) Tape electronic thermistor probe to the abdominal skin. B.) Obtain the temperature orally. C.) Place electronic temperature probe in the midaxillary area. D.) Obtain the temperature rectally.
Answer: C.) Place electronic temperature probe in the midaxillary area.
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.
Answer: C.) The newborn will experience no bleeding episodes lasting more than 5 minutes. Rationale: 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.
When examining a newborn's eyes, the nurse would expect which assessment? A.) follows your finger a full 180 degrees B.) has a white rather than a red reflex C.) follows a light to the midline D.) produces tears when he cries
Answer: C.) follows a light to the midline Rationale:
A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse? A.) "Be sure to keep the newborn's umbilical cord stump clean and dry." B.) "Keep your newborn at home and do not allow visitors for the first month." C.) "Be sure to keep all scheduled doctor appointments for vaccinations." D.) "Always wash your hands before you pick up or provide care to your newborn."
Answer: D.) "Always wash your hands before you pick up or provide care to your newborn." Rationale: 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.
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? A.) Suction the mouth and then the nose with a suction catheter. B.) Place the newborn on its stomach with the head down and gently pat its back. C.) Suction the nose first and then the mouth with a bulb syringe. D.) Using a bulb syringe, suction the mouth then the nose.
Answer: D.) Using a bulb syringe, suction the mouth then the nose.
New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? A.) "We'll turn on the mobile that's hanging above his head in his crib." B.) "We'll lightly rub his back as we talk to him softly." C.) "We'll swaddle him snuggly to make him feel secure." D.) "We'll hold off on feeding him for a while because he might be too full."
Answer: D.) "We'll hold off on feeding him for a while because he might be too full." Rationale: Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. 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 to him. Swaddling the newborn provides security and comfort.
A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term? A.) 1,200 grams B.) 1,800 grams C.) 2,200 grams D.) 3,500 grams
Answer: D.) 3,500 grams Rationale: Typically, the term newborn weighs 2,500 to 4,000 g. Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation. A newborn weighing less than 1,500 grams is considered very-low-birth-weight. A newborn weighing 1,800 grams or 2,200 grams would be considered low-birth-weight.
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? A.) Lower rate of urinary tract infections B.) Reduced risk of penile cancer C.) Fewer complications than if done later in life D.) Anesthetic may not be effective during the procedure
Answer: D.) Anesthetic may not be effective during the procedure Rationale: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? A.) Send a family member to accompany the infant when leaving the room. B.) Check the name on the baby's identification bracelet. C.) Provide a list of approved visitors who came spend time with the infant. D.) Check the identification badge of any health care worker before releasing baby from room.
Answer: D.) Check the identification badge of any health care worker before releasing baby from room. Rationale: Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.
The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? A.) Use of pass codes onto the unit B.) Use of monitor attached to babies C.) Use of cameras at all doors D.) Cooperation by the parents with the hospital policies
Answer: D.) Cooperation by the parents with the hospital policies Rationale: The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.
The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? A.) Ineffective thermoregulation related to heat loss to the environment B.) Altered nutrition less than body requirement related to limited formula intake C.) Altered urinary elimination related to postcircumcision status D.) Ineffective airway clearance related to mucus and secretions
Answer: D.) Ineffective airway clearance related to mucus and secretions
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).
Answer: D.) It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). Rationale; 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.
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? A.) The infant may sleep through the night around 2 months of age. B.) Caregivers need to sleep while the baby is sleeping. C.) Newborns usually sleep for 16 or more hours each day. D.) Place the infant on the back when sleeping.
Answer: D.) Place the infant on the back when sleeping.
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? A.) Wipe the tongue off vigorously to remove the white patches. B.) Rinse the tongue off with sterile water and a cotton swab. C.) Since it looks like a milk curd, no action is needed. D.) Report the finding to the pediatrician.
Answer: D.) Report the finding to the pediatrician. Rationale: 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.
While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? A.) bruising from the birth process B.) an immature autoregulation of blood flow C.) an allergic reaction to the soap used for the first bath D.) concentration of immature blood vessels
Answer: D.) concentration of immature blood vessels Rationale: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns. An allergic reaction would be more generalized and would not be salmon-colored.
A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor? A.) lanugo B.) vascular nevi C.) bruising D.) congenital dermal melanocytosis (slate gray nevi)
Answer: D.) congenital dermal melanocytosis (slate gray nevi)
A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. - Provide warm water to drink. - Provide oxygen supplementation. - Massage the newborn's back. - Ensure the newborn's warmth. - Observe respiratory status frequently.
Answer; - Provide oxygen supplementation. - Ensure the newborn's warmth. - Observe respiratory status frequently. Rationale:
A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? A.) Moro reflex B.) square window C.) popliteal angle D.) scarf sign
Answer; A.) Moro reflex Rationale; There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.
When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse documents this finding as: A.) milia. B.) lanugo. C.) vernix caseosa. D.) harlequin sign.
Answer; B.) lanugo. Rationale: Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. Harlequin sign refers to a transient phenomenon in which a newborn appears red on the dependent side of the body and pale on the upper side when lying on his or her side.
The Ballard scoring system evaluates newborns on which two factors? A.) body maturity and cranial nerve maturity B.) physical maturity and neuromuscular maturity C.) skin maturity and reflex maturity D.) tone maturity and extremities maturity
Answer; B.) physical maturity and neuromuscular maturity
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? A.) Swaddle the infant and place in the bassinet. B.) Complete a full head-to-toe assessment. C.) Assess the newborn's glucose level. D.) Dry the newborn and place it skin-to-skin on mother.
Answer; D.) Dry the newborn and place it skin-to-skin on mother.