Newborn

When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding? 1. Irritability 2. Poor feeding 3. Shivering 4. Weak cry

3. Shivering Educational objective: Premature infants are at high risk for cold stress due to decreased brown adipose tissue and inability to generate heat by shivering. The nurse should carefully assess for signs of cold stress, which include decreased temperature, altered mental status, bradycardia, hypoxia, hypotonia, and a weak cry and/or suck.

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy muscle tone 3. Microcephaly and cleft palate 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools

1. Irritability and restlessness 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools Educational objective: Prenatal exposure to illicit drugs may result in neonatal abstinence syndrome. A history of opioid abuse is the most common cause. Manifestations may include irritability, restlessness, a high-pitched cry, nasal congestion, frequent yawning/sneezing, poor feeding, and diarrhea.

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3 hours 4. Runny, seedy, yellow stool

1. 10% weight loss since birth During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option 1). Educational objective: During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation.

The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider? 1. A sudden jarring of the client's crib does not produce a Moro reflex. 2. The client has swollen labia and a thin, white vaginal discharge. 3. The posterior fontanel is triangular and smaller than the anterior fontane. 4. There are pearly, white pinpoint papules on the client's face and nose.

1. A sudden jarring of the client's crib does not produce a Moro reflex. Primitive newborn reflexes help determine the client's neurological status and development. The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position. Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provider (Option 1). Educational objective:The Moro (startle) reflex is elicited in newborns by simulating a falling sensation; the infant extends and raises the arms and then curls into the fetal position. An absent Moro reflex may indicate brain or spinal cord underdevelopment or damage.

Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply. 1. Abundant lanugo on shoulders and back 2. Deep creases and peeling skin on soles of feet 3. Flat areolae without palpable breast buds 4. Smooth, pink skin with visible veins 5. Testes completely descended into the scrotum

1. Abundant lanugo on shoulders and back 3. Flat areolae without palpable breast buds 4. Smooth, pink skin with visible veins A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns. This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which correlates to an estimation of gestational age. Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body (Option 1). The 28-week newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat (Option 4). The areolae of extremely premature infants may be barely visible, with no raised breast buds (Option 3). Palpable, raised breast buds measuring 5-10 mm would be expected in newborns closer to term gestation. Educational objective:A gestational age assessment assists the nurse in providing developmentally appropriate care for preterm newborns. The newborn at 28 weeks gestation has abundant lanugo; flat areolae without palpable breast buds; and smooth, pink skin with visible veins.

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. 1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 2. Holosystolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 3. Respirations of 56 breaths per minute 5. White papules on bridge of the nose During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal (Option 1). A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute (Option 3). Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks (Option 5). objective:Expected findings for a neonate at 1-3 hours postpartum include respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply. 1. Chest wall retractions 2. Desquamation of the feet 3. Head circumference of 13.5 in (34 cm) 4. Jaundiced appearance 5. No voiding in 24 hours

1. Chest wall retractions 4. Jaundiced appearance 5. No voiding in 24 hours When caring for newborns, the nurse should recognize abnormal findings and report them to the health care provider. Some abnormal newborn findings include: Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment (Option 1). Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and progress to the trunk and extremities (Option 4). Although newborn jaundice after 24 hours of life is usually physiologic and resolves spontaneously, it should still be reported and monitored closely to ensure resolution. No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration (Option 5). Educational objective: When caring for newborns, the nurse should recognize abnormal findings (eg, jaundice, failure to void within 24 hours, signs of respiratory distress [eg, chest wall retractions]), and report them to the health care provider for further assessment.

The nurse is caring for a 6-hour-old, full-term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. What is the nurse's first action? 1. Feed the newborn 2. Notify the health care provider 3. Place the newborn under a radiant warmer 4. Prepare to administer IV glucose

1. Feed the newborn Hypoglycemia occurs commonly in newborns of mothers with diabetes due to elevated insulin levels and consumption of stored glucose. Common signs include poor feeding, jitteriness, and irritability. Asymptomatic newborns with low blood glucose (<40-45 mg/dL [2.2-2.5 mmol/L]) should be fed breast milk or formula immediately

The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider? 1. Hemoglobin level of 24.9 g/dL (249 g/L) 2. Murmur noted on heart auscultation 3. Newborn becomes fatigued during feeding 4. Newborn has gained 0.6 lb (0.3 kg) since birth

1. Hemoglobin level of 24.9 g/dL (249 g/L) Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poorly oxygenated blood. To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-carrying RBCs. Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or hematocrit >65%). Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and additional interventions such as IV hydration and (possibly) partial exchange transfusion are required (Option 1). Educational objective: Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because increased circulatory viscosity increases the risk for thrombus formation and stroke.

The nurse is preparing to teach the perinatal unit staff about caring for newborns with either omphalocele or gastroschisis. Which of the following statements are appropriate for the nurse to include? Select all that apply. 1."An omphalocele with an intact peritoneal sac should be covered with a sterile, nonadherent dressing immediately after birth." 2. "If immediate surgical repair of the defect is planned, the newborn should be fed via a nasogastric tube instead of breastfed." 3. "Newborns with omphalocele or gastroschisis require IV access for fluid and electrolyte replacement." 4. "Newborns with omphalocele or gastroschisis should be monitored closely for temperature instability and infection." 5. "Petroleum jelly should be applied to the exposed bowel of newborns with gastroschisis before it is covered with plastic."

1."An omphalocele with an intact peritoneal sac should be covered with a sterile, nonadherent dressing immediately after birth." 3. "Newborns with omphalocele or gastroschisis require IV access for fluid and electrolyte replacement." 4. "Newborns with omphalocele or gastroschisis should be monitored closely for temperature instability and infection." Omphalocele and gastroschisis are congenital defects of the abdominal wall. An omphalocele occurs when bowel, usually covered with a peritoneal sac, herniates through the abdominal wall via the umbilical opening. Gastroschisis occurs when bowel herniates through the abdominal wall without a protective peritoneal sac. Immediately after birth, the nurse should cover the herniated bowel to prevent injury; a nonadherent dressing (eg, plastic bowel bag; sterile, saline-soaked gauze covered by loose plastic) is necessary to prevent fluid loss and protect the bowel from drying (Option 1). The nurse should monitor for temperature instability, infection, and fluid loss and initiate IV access to facilitate antibiotic administration and fluid and electrolyte replacement (Options 3 and 4). Educational objective: Omphalocele and gastroschisis are congenital defects of the abdominal wall that place the newborn at risk for temperature instability, infection, and fluid loss. Immediately after birth, the nurse should cover the herniated bowel with a nonadherent dressing (eg, plastic bowel bag; sterile, saline-soaked gauze covered by loose plastic) and initiate IV access.

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? 1. Encourage parents to increase skin-to-skin care 2. Measure abdominal girth daily 3. Measure rectal temperature every 3-4 hours 4. Position client on side and check diaper for stool

2. Measure abdominal girth daily Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. Educational objectives: Necrotizing enterocolitis is a life-threatening complication in premature infants due to underdeveloped intestine and gut immunity. Frequent abdominal girth measurements are essential to assess for worsening distension. Clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation.

The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit. What would be an appropriate action for the nurse to complete? Click the exhibit button for additional information. 1. Assess the infant's hemoglobin, hematocrit, and platelet levels 2. Measure and document the size and location of the markings 3. Notify the health care provider of the markings immediately 4. Review the delivery record for evidence of a traumatic birth

2. Measure and document the size and location of the markings Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian). Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments. Educational objective: Congenital dermal melanocytosis (mongolian spots) is a benign discoloration of the skin typically found on the back or buttocks. It is most often seen in newborns of ethnicities with darker skin tones. The spots are usually bluish gray and may be misidentified as bruising in future health care assessments. Proper documentation is essential to avoid misinterpretation of findings.

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

2. Plantar creases up the entire sole 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. (Option 1) The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks. (Option 3) Jaundice is best assessed in natural lighting, with gentle pressure to the skin over a firm surface such as the nose, forehead, or sternum. It first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. It is usually related to problems of the liver. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system. The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. objective:Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls.

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response? 1. Reassure the mother that it takes time to learn how to care for a baby while quickly changing the diaper 2. Suggest that the mother change the diaper as the nurse watches 3. Tell the mother that it is time to take over changing the baby's diaper as she will have to do it once discharged 4. Tell the mother that the nurse will change the baby's diaper while she watches

2. Suggest that the mother change the diaper as the nurse watches According to the Rubin theory, there are 3 phases of postpartum adaptation to motherhood. Taking-in: In the first 24-48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is more dependent on the health care team to help with care of the baby. Taking-hold: During 2-10 days postpartum, the mother still is learning the technical skills of mothering but may feel inadequate. Letting-go: After 10 days postpartum, the mother becomes comfortable with the new role. Research indicates that new mothers adapt to their role today more quickly than they did during the 1960s, when the Rubin theory was developed. This mother is still learning to care for the newborn. Therefore, letting her change the diaper will allow the nurse to assess her diaper changing skills and provide education as needed. Educational objective:There are 3 distinct phases of postpartum adjustment to motherhood, as outlined by Rubin.

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days." 2. "I should let the cord fall off by itself, in about 1-2 weeks." 3. "I should use a cotton swab to gently apply alcohol to the cord." 4. "I will fold the diaper below the cord to allow the cord to dry."

3. "I should use a cotton swab to gently apply alcohol to the cord." Proper care of the umbilical cord stump facilitates healing and reduces infection and bleeding risks. The primary goal of cord care is to keep the cord stump clean and dry, which reduces infection risk. Additional teaching points regarding cord care include: Keep the cord stump open to air when possible to allow for adequate drying. Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump (previously common practice); current recommendations are to avoid such solutions due to the potential for skin irritation (Option 3). Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider. Educational objective:The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.

The nurse is performing an Apgar assessment on a newborn client at 1 minute of life. The newborn is completely blue, has a heart rate of 110/min, and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned. Which Apgar score should the nurse assign this newborn? 1. Apgar score of 4 2. Apgar score of 5 3. Apgar score of 6 4. Apgar score of 8

3. Apgar score of 6 The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Apgar scoring is done at 1 and 5 minutes of life. Apgar scores do not predict future neurologic outcomes, nor should assigning Apgar scores delay the decision to initiate resuscitation. An Apgar score of 6 at 1 minute of life is appropriate for a newborn with the following findings: Completely blue (0 points for appearance/color of skin) Heart rate >100/min (2 points for pulse) Grimaces during stimuli (eg, nasal suction) (1 point for grimace/reaction) Actively moves with good tone (ie, flexion of arms and legs) (2 points for activity/muscle tone) Emits a weak cry (1 point for respiratory effort) Apgar scoring is repeated every 5 minutes for up to 20 minutes if the 5-minute Apgar score is <7. Scores <7 indicate difficulty transitioning and may require further interventions (eg, oxygen, suctioning) in addition to typical supportive measures (eg, stimulating, drying, warming). Educational objective: The Apgar score is an assessment tool used to describe how well a newborn is transitioning to extrauterine life. Scores are assigned at 1 and 5 minutes of life. If the 5-minute Apgar score is <7, it is repeated every 5 minutes for up to 20 minutes.

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene? 1. Cyanosis of hands and feet 2. Heart rate of 165/min while crying 3. Jitteriness 4. Respirations of 60/min

3. Jitteriness Newborns whose mothers have diabetes mellitus are at increased risk for complications after birth, most commonly hypoglycemia but also hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. During intrauterine life, exposure to elevated maternal glucose levels causes the fetus to produce high levels of insulin. After birth, the newborn loses the maternal supply of glucose but continues to produce high levels of insulin, as during intrauterine life, increasing the risk of hypoglycemia (ie, blood glucose <40-45 mg/dL [2.2-2.5 mmol/L]). Symptoms of hypoglycemia, usually noted in the first several hours after birth, include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability. Immediate intervention is required to prevent neurologic damage (Option 3). Educational objective: Newborns whose mothers have diabetes mellitus are at increased risk for hypoglycemia, especially in the first several hours after birth. A common symptom of newborn hypoglycemia is jitteriness. Newborn hypoglycemia requires immediate intervention to prevent neurologic damage.

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding. 2. Demonstrates to the mother how to use an electric breast pump 3. Provides supplemental formula feedings until improved breastfeeding occurs 4. Shows the mother how to hand express breast milk

3. Provides supplemental formula feedings until improved breastfeeding occurs Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflex; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option 3). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) Educational objective:Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful.

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth 2. Tiny blood streaks in the vomit 3. Vomit that is green 4. Vomiting through the nose

3. Vomit that is green Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. Educational objective: It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction.

The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction? 1. "I will allow my baby to sleep with a pacifier." 2. "I will dress my baby in a sleep sack to prevent my baby from getting cold." 3. "I will make sure there is a firm mattress in the crib." 4. "I will tie bumper pads to the sides of the crib to protect my baby's head."

4. "I will tie bumper pads to the sides of the crib to protect my baby's head." Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses should inform caregivers about childcare practices that reduce the risk of SIDS, including: Place infant on the back to sleep on a firm surface every time. Infants should not share a bed with anyone. Avoid soft objects (eg, stuffed animals, pillows) in the infant's bed. Nothing in the bed with the infant is safest. Avoid bumper pads for the crib. Newer cribs do not require bumper pads because improved side rails prevent the infant's head from getting stuck between slats (Option 4). Maintain a smoke-free environment. Avoid overheating. Infants do not require more than one extra layer than adults require to be comfortable. Breastfeed and ensure immunizations are updated. Educational objective: To reduce the risk of sudden infant death syndrome, infants should always be placed in their own bed, on their backs, and on a firm surface without loose bedding or toys. Prevention also includes a smoke-free environment, breastfeeding, pacifiers, avoidance of overheating, and immunizations.

The nurse is providing education about the vitamin K injection to the parents of a newborn client. Which statement by the nurse is appropriate? 1. "After the first week of life, vitamin K deficiency poses no risk to the newborn." 2. "If your prenatal diet was high in vitamin K, the vitamin K injection provides little benefit to the newborn." 3. "Vitamin K deficiency is known to cause growth delays in newborns." 4. "Vitamin K is essential for preventing bleeding, which can occur spontaneously or after procedures such as circumcision."

4. "Vitamin K is essential for preventing bleeding, which can occur spontaneously or after procedures such as circumcision." Physiologically, vitamin K levels in the newborn are very low immediately after birth and may result in vitamin K deficiency bleeding (VKDB) (ie, hemorrhagic disease of the newborn). Several factors contribute to vitamin K deficiency. First, vitamin K does not readily cross the placenta, and nonpathogenic bacteria necessary for vitamin K synthesis are absent from the newborn's gut for several days after birth. In addition, low amounts of vitamin K are present in breastmilk. The nurse should educate parents of newborns that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhage from various sources (eg, circumcision site, umbilical stump, brain, intestines) (Option 4). Therefore, an IM injection of vitamin K is routinely recommended for newborns in the first hours of life. Educational objective: Newborns should routinely receive an IM injection of vitamin K soon after birth. The nurse should teach parents that vitamin K supplementation is necessary for promoting blood coagulation and reducing the risk of life-threatening hemorrhag

A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene? 1. "IM injections will be given after the newborn's bath to reduce exposure to bodily fluids during needle sticks." 2. "The newborn will receive both the hepatitis B vaccination and hepatitis B immune globulin injection after birth." 3. "You may safely initiate skin-to-skin contact after birth, which promotes bonding and keeps the newborn warm." 4. "You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk."

4. "You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk." Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B immune globulin (HBIG) within 12 hours of birth. Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute contraindications to breastfeeding exist. Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately administered (Option 4). Educational objective: Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn. It is not a contraindication to breastfeeding. However, the hepatitis B immune globulin and vaccine should be administered to the newborn within 12 hours of birth.

The nurse is caring for a 1-day-old client at term gestation who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother informs the nurse that she has been taking hydrocodone on a regular basis for several years. Which intervention is appropriate to include in the newborn's plan of care? 1. Avoid giving the newborn a pacifier 2. Position the newborn supine after feeding 3. Stimulate the newborn with light regularly 4. Swaddle and gently rock the newborn

4. Swaddle and gently rock the newborn The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness. The nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation. If signs of overstimulation (eg, sneezing, arching) continue, then gentle, rhythmic rocking may soothe the newborn (Option 4). Educational objective:The newborn of a mother who is opioid-dependent is at high risk for neonatal abstinence syndrome. Swaddling and gentle, rhythmic rocking can soothe the newborn, minimize stimulation, and prevent skin excoriation from excessive movement caused by hyperactivity and restlessness.

The nurse is performing an assessment on a 24-hour-old male who was born breech via vaginal birth at 36 weeks gestation. Which assessment finding requires immediate evaluation by the health care provider? 1. Foreskin adheres to the glans penis 2. Scrotum is mildly edematous 3. Testes are palpated in the inguinal canal 4. Two wet diapers are noted since birth but no meconium

4. Two wet diapers are noted since birth but no meconium. An imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage. The anus may be absent or nonpatent, causing stool accumulation in the intestines or, rarely, stool excretion via a fistula between the rectum and genitourinary system (eg, vagina, male urethra). During a newborn assessment, the nurse should carefully examine the anorectum for malformation and determine anal patency by monitoring the location and quantity of stool excretion. If no stool (ie, meconium) is noted within 24 hours of birth, the nurse should notify the health care provider because immediate evaluation of the client is necessary to facilitate diagnosis and correction (eg, surgical intervention) of the suspected defect (Option 4). objective: Imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage. If no stool (ie, meconium) is noted within 24 hours of birth, the nurse should request immediate evaluation of the newborn to facilitate diagnosis and correction of the suspected defect.

A nurse is assessing a newborn with an infection due to Candida albicans. Which assessment data support this diagnosis? 1. Diffuse skin rash that resembles flea bites 2. Small, white cysts on the hard palate 3. Vesicles on the skin surrounding the lips 4. White, adherent patches on the tongue and palate

4. White, adherent patches on the tongue and palate Manifestations of oral candidiasis (thrush) include white patches on the oral mucosa, palate, and tongue. The patches are nonremovable and tend to bleed when touched. The affected infant may have difficulty sucking or feeding due to the associated pain. Thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene. The infection is usually self-limiting, but treatment with a fungicide (eg, nystatin) may hasten recovery. Educational objective:Oral candidiasis (thrush) is a fungal infection. Manifestations include white patches on the oral mucosa, palate, and tongue, and difficulty sucking or feeding. The patches are nonremovable and tend to bleed when touched.

A nurse is preparing to teach the parents of a newborn about newborn safety. Which instruction is appropriate for the nurse to include in the teaching plan? 1. "Dress the newborn in a wearable blanket, such as a sleep sack, during sleep if an extra layer is needed." 2. "Layer the newborn with jackets and blankets before securing the car seat harness." 3. "Place the newborn in the prone position while sleeping." 4. "Place the newborn's car seat facing forward."

1. "Dress the newborn in a wearable blanket, such as a sleep sack, during sleep if an extra layer is needed." Principles of newborn safety should be reinforced during postpartum discharge teaching. The following safe sleep practices help prevent sudden infant death syndrome: Dress newborns in no more than one more layer of clothing than an adult requires. A wearable blanket (ie, sleep sack) can keep the newborn warm and prevents the head from being covered (Option 1). Always place the newborn in the supine position during sleep (Option 3). Educational objective: Newborn safety teaching should include use of a newborn sleep sack, which keeps the newborn warm while preventing the head from becoming covered; supine sleep position; no loose bedding; and proper car safety seat use (eg, snuggly fitted harness, rear-facing, back seat).

The nurse is planning care for a newborn client at term gestation who is large for gestational age. Which of the following are appropriate interventions to include in the plan of care? Select all that apply. 1. Assess newborn for birth-related injuries 2. Discuss the need for feeding supplementation if symptoms of hypoglycemia occur 3. Encourage the mother to breastfeed the newborn every 2-3 hours 4. Notify the health care provider if capillary blood glucose is <45 mg/dL (2.5 mmol/L) 5. Perform capillary blood glucose checks prior to feedings

1. Assess newborn for birth-related injuries 2. Discuss the need for feeding supplementation if symptoms of hypoglycemia occur 3. Encourage the mother to breastfeed the newborn every 2-3 hours 4. Notify the health care provider if capillary blood glucose is <45 mg/dL (2.5 mmol/L) 5. Perform capillary blood glucose checks prior to feedings Newborns who are large for gestational age (LGA) are diagnosed after birth by plotting their birth weight and gestational age on a growth chart; weight must be at least >90th percentile and is commonly >8 lb 13oz (4000 g). Risk factors include gestational diabetes; excessive gestational weight gain or elevated prepregnancy BMI; history of a prior newborn who was LGA; postterm gestation; and genetics (eg, male sex, maternal birth weight, ethnicity). The nurse should prioritize assessment of birth injuries and hypoglycemia. When developing the plan of care for a newborn who is LGA, the nurse should include the following interventions: Document gestational age assessment, weight, length, and head circumference to identify newborns who are LGA. Assess the newborn for birth-related injuries (eg, cephalohematoma, clavicular fracture, lacerations) and review the birth record to determine if an operative vaginal birth occurred (eg, forceps) (Option 1). Discuss the need for possible feeding supplementation (eg, breastmilk, formula) if the newborn is hypoglycemic (Option 2). Assist the mother to feed the newborn soon after birth and every 2-3 hours thereafter to prevent hypoglycemia (Option 3). Obtain a capillary blood glucose (BG) before feeding to assess for hypoglycemia, and notify the health care provider when a capillary BG reading is <40-45 mg/dL (2.2-2.5 mmol/L) (Options 4 and 5).

he nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply. 1. Burp during and after feeds 2. Engage baby in active play after the feeding 3. Feed baby in side-lying position 4. Hold baby upright 20-30 minutes after each feeding 5. Offer smaller but more frequent feeds 6. Place baby on tummy after feeding

1. Burp during and after feeds 4. Hold baby upright 20-30 minutes after each feeding 5. Offer smaller but more frequent feeds Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk over an air pocket, the milk will come up with the burp (Option 1). Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the food in the stomach while the stomach settles (Option 4). Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full and expelling extra milk and allows for more complete emptying before the next feed. It also ensures that the child is getting the required ounces daily (Option 5). Educational objective: Infants with gastroesophageal reflux should be offered small, frequent feeds; burped frequently during the feeding; and kept in an upright position during and after feedings.

The postpartum nurse is documenting client care at the unit's front desk. During that time, several clients request assistance from the nurse. Which client need should the nurse address first? 1. Client reports that a suspicious visitor is walking up and down the hallway 2. Client reports that her newborn is uncontrollably crying and having difficulty breastfeeding 3. Client who had a cesarean birth 8 hours ago is requesting to ambulate for the first time(5%) 4. Client who is receiving IV antibiotics for postpartum endometritis reports that the IV pump is beeping

1. Client reports that a suspicious visitor is walking up and down the hallway Newborns are a vulnerable client population, and nurses play an important role in establishing a culture of safety and preventing infant abduction. Security measures may include matching mother/newborn identification bracelets; newborn security sensors; locked perinatal units; specific uniforms for nursing staff; unit-specific badges; and hospitalwide, overhead emergency alerts (eg, code pink for infant or child abduction). Nurses should frequently educate parents about newborn safety and security procedures throughout the hospital admission and remain diligent and aware of any suspicious persons on the unit. The postpartum nurse must prioritize a quick response to any perceived or reported threat to newborn security to prevent infant abduction (Option 1). Educational objective:Nurses should educate parents about newborn safety and security procedures throughout the hospital admission and remain diligent and aware of any suspicious persons on the unit. The nurse must prioritize responding to any perceived or reported threat to newborn security quickly to prevent infant abduction.

The nurse is performing postdelivery care of a newborn delivered at 35 weeks gestation. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Covers the scale with warmed blankets before weighing the newborn 2. Encourages skin-to-skin contact between the stable newborn and mother 3. Performs diaper changes underneath a radiant warmer 4. Places the identification band on the newborn before beginning to dry off amniotic fluid 5. Transfers the swaddled newborn to the neonatal intensive care unit in an open bassinet

1. Covers the scale with warmed blankets before weighing the newborn 2. Encourages skin-to-skin contact between the stable newborn and mother 3. Performs diaper changes underneath a radiant warmer Preterm newborns are at high risk for cold stress due to immaturity of the thermoregulatory center in the brain, inadequate subcutaneous fat, and an inability to initiate shivering. These attributes make it difficult for the preterm newborn to maintain normal body temperature (axillary temperature of 97.7-99.5 F [36.5-37.5 C]). Covering the scale with warmed blankets protects against conductive heat loss, which may occur when the newborn's skin comes into contact with a cooler surface (Option 1). Skin-to-skin contact with the parents for stable, preterm newborns promotes thermoregulation through conduction of body heat to the newborn (Option 2). Radiant warmers and incubators provide heat through convection and are routinely used to help newborns regulate their core temperatures. Providing care underneath the radiant warmer protects newborns from convection heat loss by reducing exposure to the cooler ambient environment and air drafts (Option 3). Educational objective: Preterm newborns are at increased risk for cold stress and heat loss. The nurse can help prevent cold stress by covering cool surfaces with warm blankets, completely drying the newborn after birth, providing care in the radiant warmer, transferring the newborn in a prewarmed incubator, and encouraging skin-to-skin contact.

A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support. The client's parents have repeatedly asked when their child will be able to breathe without the ventilator. Which action by the nurse is appropriate? 1. Facilitate a meeting between the health care providers, palliative care team, and parents to discuss care plan 2. Notify the parents of the newborn's genetic test results and provide information to read about trisomy 18 3. Provide the parents with information about various options for curative medical treatment for their child 4. Share with the parents that many newborns with trisomy 18 live long enough to go home with their families

1. Facilitate a meeting between the health care providers, palliative care team, and parents to discuss care plan Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers (HCPs) and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care (Option 1). Educational objective: Trisomy 18 (Edwards syndrome) is a life-threatening chromosomal abnormality. Many of those affected will die in the first week of life and most do not make it to the first birthday. The nurse should request a collaborative meeting between the health care providers and the palliative care team to help the parents understand their infant's condition and make decisions.

A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed? 1. "Discharge and odor indicate infection of the circumcision site." 2. "I will clean the area with alcohol-based wipes or soap water." 3. "Infant crying during petrolatum gauze changes is expected." 4. "The diaper should be changed at least every 4 hours."

2. "I will clean the area with alcohol-based wipes or soap water." Common complications of circumcision include hemorrhage, infection, and voiding difficulty. Parents should clean the area with warm water (without soap) to remove urine and feces and prevent infection. Prepackaged alcohol-based wipes delay healing and cause discomfort; they should be avoided until the circumcision site has healed (usually takes 5-6 days). Educational objective: In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

The nurse is caring for an exclusively breastfed, small-for-gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose (BG) of 30 mg/dL (1.67 mmol/L) and is asymptomatic. Which action is most appropriate for the nurse to take at this time? 1. Administer IV glucose 2. Allow the newborn to breastfeed 3. Obtain a prescription for formula supplementation 4. Wait for plasma blood sample to confirm BG prior to feeding

2. Allow the newborn to breastfeed Educational objective: Asymptomatic hypoglycemia in newborns with blood glucose <35 mg/dL (<1.94 mmol/L) if age 4-24 hours or <25 mg/dL (<1.39 mmol/L) if age <4 hours should be initially treated with feeding. Feeding is a simple, noninvasive method of increasing and stabilizing blood glucose

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy? 1. Allowing the parents to feed the newborn 2. Applying a shirt while the newborn is exposed to phototherapy 3. Assessing the temperature of the incubator while the newborn is inside 4. Covering the newborn's eyes with protective shields

2. Applying a shirt while the newborn is exposed to phototherapy Phototherapy is the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine. The newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and breakdown. Educational objective: The newborn should be fully exposed, except for a diaper, when placed under phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output.

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take? 1. Administer epinephrine 2. Begin positive pressure ventilation 3. Continue stimulating the newborn 4. Start chest compressions

2. Begin positive pressure ventilation Newborns are evaluated immediately after birth for adaptation to extrauterine life. Newborns requiring resuscitative measures should be cared for using structured, evidence-based interventions, such as the neonatal resuscitation program (NRP) algorithm. Each step of the NRP algorithm requires rapid assessment and decision-making at 30-second intervals. NRP dictates that positive pressure ventilation (PPV) be started when a newborn's heart rate is <100/min. Effective PPV will often result in a rising heart rate and return of spontaneous respirations. Educational objective: Neonatal resuscitation interventions after birth are initiated at 30-second intervals, with continual assessment of the newborn's adaptation to extrauterine life. Positive pressure ventilation (PPV) is started if heart rate is <100/min; compressions are started if the newborn's heart rate remains <60/min after at least 30 seconds of quality PPV.

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple

2. Burping the infant often 3. Feeding in an upright position 5. Using a specialty bottle or nipple A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. Educational objective: Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20-30 minutes, using special nipples or bottles, and feeding every 3-4 hours. The infant should be burped at regular intervals to reduce gastric distension.

The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply. 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate of 150/min 4. Sacral dimple with a 0.4 in (1 cm) skin tag 5. Single artery in the umbilical cord

2. Decreased muscle tone 4. Sacral dimple with a 0.4 in (1 cm) skin tag 5. Single artery in the umbilical cord Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further intervention. Unexpected findings in newborns include: Decreased muscle tone (ie, hypotonia), which may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury (Option 2). Newborns normally have increased muscle tone and should resist movement of the extremities. Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally (Option 4). Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart (Option 5). Normal umbilical cords contain 2 arteries and 1 vein.

The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refusal to feed

2. Distended abdomen 3. Has not passed stool (meconium) 5. Refusal to feed Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They will also have difficulty feeding and often vomitgreen bile. Educational objective: Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. Infants with Hirschsprung disease will not pass meconium but will have distended abdomens and bilious emesis.

The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding? 1. Bilateral rales found on lung auscultation 2. Dullness over bladder found on percussion 3. Ptosis of right eyelid found on facial inspection 4. Single testicle found on genital palpation

3. Ptosis of right eyelid found on facial inspection Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve. This finding warrants further investigation. At the time of birth, there should be no cranial nerve abnormalities. Educational objective: At the time of birth, there should be no cranial nerve abnormalities. Rales (crackles) indicate fluid in the lungs and will clear as the neonate transitions to extrauterine life. Most undescended testes descend spontaneously by age 6 months.

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate? 1. Apply blow-by oxygen and count respirations 2. Auscultate heart sounds for a murmur 3. Observe the newborn for expiratory grunting 4. Place the newborn skin-to-skin with the mother

4. Place the newborn skin-to-skin with the mother Acrocyanosis or peripheral cyanosis of the hands and feet is a benign finding during a newborn's transition to extrauterine life. It is especially common during the first 24 hours of life or in the first week if the newborn is cold. Manifestations include a bluish discoloration of the hands and feet and sometimes the skin around the mouth. Acrocyanosis results from poor perfusion to the periphery of the body, an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management includes promoting thermoregulation by placing the newborn skin-to-skin with the mother or under a radiant warmer and assessing axillary temperature (Option 4). objective:Acrocyanosis manifests as a bluish discoloration of the newborn's hands and feet; it is considered a normal finding during the first day of life or if the newborn becomes cold. The best nursing action is to promote warmth by placing the newborn skin-to-skin with the mother.

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention? 1. Abdominal breathing with 15-second pauses in a sleeping newborn 2. Apical pulse of 190/min in a newborn who is crying 3. Heart murmur in a newborn who is feeding appropriately 4. Respirations of 68/min with grunting in a newborn post cesarean birth

4. Respirations of 68/min with grunting in a newborn post cesarean birth Newborns normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection The newborn should be placed on continuous monitoring and may require respiratory support (eg, oxygen, continuous positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes.

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1. Edema of the scalp crossing the suture lines 2. Flat, bluish, discolored area on the buttocks 3. Small tuft of hair at the base of the spine 4. White, waxy substance in the axillae and labial folds

Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required (Option 3). Educational objective: Spina bifida is a neural tube defect that occurs when spinal vertebrae do not close during fetal development, potentially allowing spinal cord contents to protrude through the opening. A tuft of hair, hemangioma, nevus, or dimple at the base of the spine may indicate the mildest form, spina bifida occulta.