Chapter 18 (Test 3)

Which of the following is FALSE regarding bathing the newborn?

To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.

Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn?

Warm all surfaces and objects that come in contact with the newborn.

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching?

"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas."

When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching?

"Use talc powders to prevent diaper rash."

Which of the following statements by the parents of a newborn indicate that they understand how to soothe their newborn if he becomes upset?

"We'll turn the mobile on that's hanging above his head in his crib."

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.

One minute after delivery, the neonate's heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate?

5

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of:

7

You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is

7 to 10.

Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs?

Blood pressure

The infant has APGAR scores of 7 at one minute and 9 at five minutes. What is the indication of this assessment finding?

Adjusting to extrauterine life

You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period?

Blood sugar

Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)?

Both A and B

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

Bright red, raised bumpy area noted above the right eye

It is common for a newborn to have one or two erupted teeth (natal teeth) at birth.

False

A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents?

Cover the glans generously with Vaseline.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein's pearls

A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition?

Erythema toxicum

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

The AGPAR score is based on which 5 parameters?

Heart rate, muscle tone, reflex irritability, respiratory effort, and color

What is the best rationale for trying to decrease the incidence of cold stress in the neonate?

If the neonate becomes cold stressed, it will eventually develop respiratory distress

Which of the following nursing diagnosis would be highest in priority for a newborn?

Ineffective airway clearance related to mucous obstruction.

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn?

Lack of subcutaneous fat

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?

Mongolian spot

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this?

Observing chest movement

A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond?

Pain administration may not be effective during the procedure

The New Ballard scoring system evaluates newborns on which 2 factors?

Physical maturity and neuromuscular maturity

The infant's temperature is 97.2°F (36.2°C) axillary an hour after birth. Which intervention is the appropriate for the nurse?

Place the infant under a radiant warmer or in a heated isolette.

Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways?

Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe?

Right upper abdominal quadrant

All of the following are ways the nurse can encourage bonding between the parents and the newborn EXCEPT

Telling the mother that the best way to bond with her baby is to breastfeed

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

The fat pads on the lateral aspects of the foot

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life.

Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission.

True

Following birth, a newborn is placed on the mother's abdomen for a period of skin-to-skin contact.

True

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

Within the first 2 to 4 hours, when the newborn reaches the nursery

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 oxygen supplementation • Ensure the newborn's warmth • Observe respiratory status frequently