Chapter 24, Nursing Care of the Newborn and Family

Which factor might account for loose stools in a newborn after phototherapy?

Bilirubin-induced gastric motility

The nurse is assessing a preterm baby and observes dark-red skin color with harlequin signs on the skin. Which condition would the nurse infer from these findings?

Polycythemia

Head circumference greater than chest circumference

Administer vitamin K intramuscularly.

Which complication is associated with high bilirubin levels in the newborn?

Kernicterus

Which recommendation would the nurse make to the parents of a newborn about traveling with the infant in a car?

Secure the infant in a rear-facing car seat in the rear of the car.

Which areas of the neonate are assessed for jaundice? Select all that apply.

Skin Buccal mucosa Conjunctival sacs

Which documentation reflects on the neurologic activity of the neonate?

The ability to suck

The nurse is assessing a term infant 1 minute after birth. The infant has a heart rate of 120 beats/min, a good cry, well-flexed extremities, and acrocyanosis. The infant cried while suctioning the nares. Which Apgar score would the nurse document for this infant? Record your answer using a whole number. ________

The infant has a heart rate greater than 100 beats/min; this is rated as 2. A good cry while initiating respiration is noted as 2. Good flexion of extremities is rated as 2. The infant has a pink body with slightly blue extremities or acrocyanosis, which has a score of 1. The infant cried while the nares were being suctioned; this reflex irritability gets a score of 2. The Apgar score for the infant is 2 + 2 + 2 + 1 + 2 = 9.

The nurse is using the CRIES pain scale to determine the pain level in a circumcised infant. What does a score of 1 for "Sleeplessness" indicate?

The infant has awakened at frequent intervals.

During a newborn assessment, the nurse notes that the heart rate is 110 beats/min, respiratory rate varies from 35 to 40 breaths/min, and the neonate has a pink complexion. Which conclusion would the nurse make based on these findings?

The neonate exhibits normal findings.

Which response would the nurse provide to the mother of a newborn who asks, "What should I do to prevent recurrence of jaundice in my baby?"

"Breastfeed your baby 10 times a day."

Which statement by the client would indicate effective learning about use of a bulb syringe when caring for her newborn?

"It is used to clear mucous and prevent airway obstruction."

Which action would the nurse take when administering erythromycin ophthalmic ointment to a newborn?

Cleanse eyes from the inner to outer canthus before administration if necessary.

A client with a history of gonorrheal infection just delivered her baby. Which immediate intervention would the nurse provide to the newborn?

Administer ophthalmic solution.

Which interpretation would the nurse have for an Apgar score of 10 at 1 minute after birth?

An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth

Which technique would the nurse use to distinguish cutaneous jaundice from the normal skin color of a neonate?

Apply pressure on the forehead with a finger.

The nurse appreciates a murmur when assessing a neonate in resting position. Which additional assessments would the nurse make to identify possible cardiac defects?

Assess blood pressure (BP) in all four extremities.

The nurse is caring for a full-term infant immediately after birth. The infant is crying and has good muscle tone. Which interventions would the nurse perform for this infant? Select all that apply.

Assess the airway, and keep the neck slightly extended. Assess the heart rate by grasping the base of the cord. Place identically numbered bands on the infant and mother.

Which method would the nurse use to assess the temperature of a neonate 12 hours after birth?

Axillary route

Which blood pressure (BP) measurements in the neonate would the nurse interpret as indicating a possible cardiac defect?

BP is 80/60 mm Hg in upper extremities and 60/40 mm Hg in lower extremities.

Which nursing plan of action is appropriate when caring for a 2-day-old newborn based on the evaluation of vital signs?

Continuing to monitor vital signs per protocol

Which technique would the nurse use when assessing the respiratory rate of a newborn 12 hours after birth? Select all that apply.

Count the rise and fall of the abdomen. Observe for symmetry of chest movement. Assess the infant's respiratory rate.

Which intervention would the nurse perform while using a fiberoptic blanket and phototherapy light for a newborn with jaundice?

Cover the newborn's eyes with an opaque mask.

Which education would the nurse provide to a client about caring for her infant with signs of overstimulation (SOS)?

Encourage the baby to breastfeed.

Which education would the nurse provide the parents of a newborn regarding postcircumcision care?

Expect a yellowish exudate to cover the glans after the first 24 hours.

Which clinical finding would the nurse interpret as a possible sign of hydrocephalus?

Head circumference greater than chest circumference

Which clinical finding would be consistent with a newborn who received an Apgar score of 4?

Heart rate of 70 beats/min

Which education would the nurse provide the parents of a neonate about how to use a bulb syringe?

Insert the tip of the bulb into the side of the mouth first.

Which education would the nurse provide the parents of an infant who was circumcised with the PlastiBell device? Select all that apply.

Inspect the circumcision at least every 4 hours. Retain yellow exudate over the glans penis. Report redness, swelling, discharge, or odor.

How would the nurse classify the gestational age of an infant born at 35 weeks?

Late preterm

Which technique would the nurse use to measure a newborn's physical growth?

Measure the circumference of the head just above the eyebrows.

Which integumentary finding for a newborn is identified as a normal variation?

Mongolian spots

Which action would the nurse take when placing a newborn under a radiant heat warmer to stabilize temperature after birth?

Perform all examinations and activities under the warmer.

Which recommendations would the nurse make to parents about ensuring safe sleep for their infant? Select all that apply.

Place the infant's crib in the parent's room. Place the infant in the supine position while sleeping. Have a firm mattress with a fitted sheet in the crib.

Which anticipatory guidance would the nurse provide the parents of a newborn at discharge? Select all that apply.

Prevent exposure to people with upper respiratory tract infections. Keep the infant away from secondhand smoke. Avoid loose bedding, waterbeds, and beanbag chairs.

The nurse reports a neonate's heart rate as 90 beats/min. Which intervention would the nurse expect the health care provider to prescribe to restore a normal heart rate?

Provide ventilation support.

Which safety measure would the nurse implement to prevent necrotizing osteochondritis when performing a heelstick on a neonate?

Puncture the skin up to 2.4 mm.

Which is the priority nursing action based on evaluation of information in the electronic health record for a 1-hour-old newborn?

Respiratory

The nurse grasps the base of the umbilical cord and counts 14 beats for 6 seconds. What is the heart rate of the newborn? Record your answer using a whole number. _____ beats/min

The nurse counts the heartbeat for 6 seconds and multiplies it by 10 to calculate the heart rate. The nurse counts 14 beats, so the heart rate of the newborn is 14 × 10 = 140 beats/min.

The nurse is caring for a neonate who has a provider prescription to apply erythromycin 0.5% ophthalmic ointment to the neonate's eyes in the first hour after birth. In which order would the nurse perform these interventions?

The nurse would don gloves and cleanse the eyes, if necessary, before administering the ointment. The nurse would place a thumb and finger at the corner of each eyelid and gently press on the periorbital ridges to open the eyes. The nurse would then squeeze the tube to apply ointment to the lower conjunctival sac without touching the tube to the eye. The ointment is spread from the inner canthus of the eye to the outer canthus. The nurse would wait for 1 minute before wiping off any excess ointment. The nurse would then observe the eyes for any irritation.

Which education would the nurse provide the parents of a neonate who has petechiae over the face and upper back?

The rash is benign if it disappears within 48 hours of birth.

Which nursing information is appropriate to include in an explanation to the parents regarding their 24-hour-old newborn who did not pass the initial hearing screening?

The screening will be repeated before discharge.

Which factor would the nurse be aware of regarding umbilical cord care?

The stump can easily become infected.

When performing a pulse oximetry to assess a newborn for congenital heart defects, which factor would the nurse bear in mind?

The test is performed in the newborn's right hand and on one foot.

Which statements are accurate regarding the proper bathing of a newborn? Select all that apply.

Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Unscented mild soap can be used to wash the infant. Powders are not recommended because the infant can inhale powder. Never leave the infant alone when bathing.

Which anticipatory guidance would the nurse provide the parents of a newborn?

Use a rear-facing car seat.

Which anatomic site would the nurse select to administer vitamin K to a term newborn?

Vastus lateralis muscle

How would the nurse administer a hepatitis B (HepB) vaccine to a neonate? Select all that apply.

Via the vastus lateralis muscle By inserting the needle at a 90-degree angle

Which action would the nurse take while performing a heelstick for an infant?

Warm the heel before obtaining the sample.

Which action would the nurse take when weighing a newborn?

Which action would the nurse take when weighing a newborn?