Chapter 67 Care of the Normal Newborn 4

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

A normal finding

The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. What does the result indicate to the nurse?

A normal level

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse bases the response on which characteristic of this disorder?

A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?

Abnormal palmar creases

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting to care for the newborn, the priority concern should be which?

Aspiration

The nurse has provided instructions to the mother of a newborn that is not circumcised about measures to clean the penis. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?

"I need to bathe my newborn after a feeding."

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?

Begin with the eyes and face.

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which?

"I will observe for signs of bleeding with each diaper change."

The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which?

Blood glucose levels

A student nurse examines an Asian-American infant's eyes and notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding?

"It probably isn't strabismus but appears that way because of the child's ethnic background."

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse should make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response?

"Surgical repair is usually around 6 to 12 weeks of age."

The nurse is caring for a newborn in the nursery and notes that the health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse should make which statement to address the client's concern?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse should make which statement?

"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

Adhere to standard precautions during delivery and in the nursery. Instruct the parents to not release their newborn infant to anyone wearing improper identification. Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse should tell the mother that which is a sign of infection?

A moist cord with discharge

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first?

Check the blood glucose level.

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action?

Clap the hand or slap on the mattress.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off

The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which finding should the nurse expect to note in the infant?

Coughing, wheezing, and short periods of apnea

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?

Covering the bladder with a sterile, nonadhering moist dressing

The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be appropriate?

Document the findings.

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action would be the best?

Document the findings.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

Drug withdrawal

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

The nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indication on data collection of the infant?

Edema caused from bleeding below the brain's periosteum

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment is characterized by which description?

Effective in protecting the newborn from Neisseria gonorrhoeae and Chlamydia

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication?

Erythromycin

A client delivers a viable neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. How does the nurse characterize the neonate's physical condition?

Good

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid?

Hard cheeses

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heel stick blood glucose

The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breast-feeding.

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother?

Increase the frequency of the breast-feeding.

The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student?

Inject into skin that has been cleansed with alcohol.

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

The nurse is caring for a neonate that is 3 hours old and should assess for which signs/symptoms of cold stress? Select all that apply.

Mottling of skin Increased respirations with apnea

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Notify the health care provider of the finding.

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Notify the registered nurse.

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care?

Observing for bleeding and monitoring for pain

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription?

Obtain written parental consent.

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are in which location?

Outside of the abdominal cavity but covered with a translucent sac

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique should the nurse anticipate being used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

A newborn has just been circumcised. Which describes how the nurse should expect the surgical site to appear?

Reddened, with a small amount of bloody drainage

The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation should the nurse make of these results?

Respiratory acidosis

The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse would indicate an understanding of a subdural hematoma?

Testing for equality of extremities when stimulating reflexes

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?

The client is experiencing a normal response to birth.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer should the nurse give to the mother?

The medication primarily decreases the number of apnea occurrences.

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply.

The newborn is irritable. The newborn cries incessantly. The newborn is difficult to console. The newborn hyperextends and postures.

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?

The passage of bloody mucous stool

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?

The process of keeping the cord clean and dry will decrease bacterial growth.

In caring for a preterm newborn's skin, which special characteristics should the nurse expect to note?

Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, the nurse might suspect that the newborn has which condition?

Tracheoesophageal fistula

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is collecting initial data on a newborn in the delivery room. Which observation should the nurse expect to note when examining the umbilical cord of the newborn?

Two arteries and one vein

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?

Warming the crib pad before placing the newborn in the crib

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges