EDAPT Nursing Care: Newborn Assessment

For each potential order or nursing action, click to specify whether it is anticipated or unrelated/unnecessary to the newborn's care.

Anticipated: Monitor blood glucose levels per protocol Monitor body temperature per protocol Reinforce education for Teresa regarding hypothermia prevention Monitor respiratory rate and status

Which two actions should the nurse take next?

Assess the newborn's blood glucose level Place the newborn in a radiant warmer

The nurse is assessing a newborn's vital signs. Which findings require follow-up? Select all that apply.

Axillary temperature 97.5°F (36.4°C) Apical heart rate 100 beats per minute Respiratory rate 20 breaths per minute

What is the concern with Teresa's newborn being hypothermic? Select all that apply.

Can lead to hypoglycemia May indicate physical immaturity May indicate inadequate thermoregulation abilities

The nurse obtains an axillary body temperature of 97ᵒF (36.1ᵒC) on a newborn. Based on this finding, what assessment cues should alert the nurse? Select all that apply.

Decreased blood oxygen saturation Hypoglycemia Lethargy

The nurse is assessing the newborn and observes all of the following findings. Indicate which findings require follow-up and which do not.

Does Not Require Follow-Up: Eyelids edematous Arms and legs remain flexed against the body Respiratory rate 40 breaths/minute with brief periods of apnea Vernix found in creases of armpits Regurgitating mucous after feeding Teresa uses skin-to-skin contact when breastfeeding

Which statement reflects the newborn's visual abilities at birth?

From birth, newborns can best see objects held 8-10 inches away.

The newborn's umbilical cord at delivery normally contains which components? Select all that apply.

Gelatinous protective tissue One vein and two arteries

The nurse observes pink stains in the diaper of a 1-day-old, male newborn. What conclusion does the nurse make based on this finding?

He has uric acid crystals in his urine.

Which additional findings indicate to the nurse that the newborn's hypothermia has been resolved?

He is alert and sucking his hand.

The nurse observes a new mother placing her newborn on the bed between her legs, then unwrapping the newborn to change the diaper and clothes. She stops to answer her phone and is observed leaving the newborn unwrapped. What implications may this have? Select all that apply.

Hypothermia in the newborn Newborn's blood glucose level may decrease Increased oxygen demand and consumption in the newborn

Drag each common newborn skin assessment finding to its description.

Milia- Small white spots on the nose and chin similar to acne Rash- Non-contagious normal response to exposure to allergens during the adjustment to extrauterine life Lanugo- Fine hairs that appear on the bodies of newborns of lower gestational age Mongolian spots- Increased pigmentation common in darker-skinned people Vernix- Skin protectant that covers the body of infants of lower gestational age; dissolves away as the fetus nears term Strawberry birthmarks and stork bites- Reddened areas that become more prominent with crying Jaundice- After 48 hours of life, yellowing skin caused by bile pigment deposits in the skin Acrocyanosis- Blue hands and feet lasting 7-10 days as circulation improves​

The nurse is assessing Teresa and her newborn and observes the following. Identify which findings correlate to the newborn's axillary temperature reading of 97.4°F.

Newborn is in his crib wearing a onesie and wrapped in one blanket Infant received a bath 20 minutes ago Birthweight 5 lbs. 0 oz., 36 weeks SGA (small for gestational age)

For each newborn assessment finding, indicate whether it is normal or requires follow-up.

Normal: Fontanelles are firm and flat Eyelids are edematous Apical Pulse rate158 beats/min Up to 7% drop in birthweight in first 24-48 hours Molding Prominent abdomen Caput Brief periods of apnea

What is the cause of molding in the newborn skull?

Overlapping of the unfused bones compressed during vaginal delivery

A 12-hour-old newborn is found to have a dark brown, sticky, thick mass of stool in his diaper. With what is this finding consistent?

The newborn digested amniotic fluid in utero.