NUR 113

Normal heart rate for a newborn

110-160 beats/min resting 100 beats/min sleeping 170 beats/min crying

Side effect/ adverse reaction of PCV

Severe: anaphylaxis Common: soreness, swelling, redness or pain to site, mild to moderate fever, irritability, drowsiness, restlessness, sleep, decreased appetite, vomiting & diarrhea, rash or hives

What do vaccines produce?

Active Immunity (antibody production is stimulated without causing clinical disease)

A newly adopted 8-year-old child is brought to the pediatric immunization clinic to begin the Hep B immunization series. Before providing the immunization, the nurse inquires about any known history of allergy to which item? a) aminoglycoside antibiotics b) mold c) Baker's yeast d) egg yolds

c) Baker's yeast

Precautions for MMR vaccine

College student are at greater risk due to increased exposure Caution females to avoid pregnancy for at least 3 months after immunization Wait at least 3-6 months after administration of immune serum globulin before giving MMR Thrombocytopenia or history of thrombocytopenia purpura

An inactivated vaccine that is given to kids to prevent Diphtheria, Tetanus, & Pertussis

DTaP

What immunizations are given between 4-6 years?

DTaP, IPV, MMR, Varicella

What immunization are given at 15 months?

DTaP, Same shots given @ 12 months if not given already)

An acute contagious infection that can cause respiratory obstruction

Diptheria

What immunization is given at birth?

Hep B

What immunizations are given between 1-2 months?

Hep B

A liver infection caused by HBV, which is transmitted in blood or body secretions (A series of 3 injections)

Hepatitis B (Hep B)

What immunizations are given at 12 months?

Hib, PCV13, MMR, Varicella, Hep A

What is passive immunity?

Immune globulins in which antibodies are already formed (breast milk) IgG

Side effect/adverse reaction to IPV

Serious: anaphylaxis Common: elevated temperature 1-2 week after immunization, redness or pain at injection site, noncontagious rash, joint pain, irritability

Side effects/ adverse reaction of Varicella

Serious: anaphylaxis Common: pain or redness to injection site, fever up to 102℉, varicella-like rash at injection site, irritability

Side effects/ adverse reactions for MMR

Serious: anaphylaxis, encephalopathy, thrombocytopenia purpura, chronic arthritis Common: elevated temperature 1-2 weeks after immunization, redness or pain at injection site, noncontagious rash, joint pain

Side effects or adverse reactions to DTaP

Serious: anaphylaxis, seizure, inconsolable crying for 3 hours or more, fever greater than 105℉ Common: redness, pain, swelling, and nodule at injection site; fever up to 101℉, drowsiness, fussiness, anorexia within 2 days of injection

Contraindications for Varicella vaccine

Instruct females not to become pregnant for at least 3 months after getting vaccinated, not recommended for those who have HIV, wait at least 3-11 months after administration of immune serum globulin, allergy to neomycin or gelatin, active or untreated TB, immunodeficiency, moderate or severe febrile illness

Pertussis (whooping cough)

Leads to respiratory distress, pneumonia, seizures, brain damage, or death

Contraindication for Hep B vaccine

Life-threatening allergic reaction to baker's yeast (used for baking bread) Serious reaction to a previous dose of Hep B vaccine including anaphylaxis Liver abnormalities

Contraindications to DTaP

Life-threatening reaction to previous dose of DTaP, Seizure, inconsolable crying for 3 hours or more, or fever above 105℉ after previous dose

A disease caused by a virus that affects CNS, may not cause serious illness, can cause paralysis, respiratory complications, & death

Poliomyelitis

What immunizations are given at 2 months?

RV, DTap, Hib, PCV13, IPV

What immunizations are given at 4 months?

RV, DTap, Hib, PCV13, IPV, Hep B

What immunizations are given at 6 months?

RV, DTap, Hib, PCV13, IPV, Influenza

Can cause muscle spasms and rigidity over entire body untimately obstructs breathing and can be fatal.

Tetanus (lockjaw)

IPV

Trivalent inactivated polio vaccine. (Do not use if it contains particulate matter, becomes cloudy, or changes color)

The nurse conducts a neurological assessment of the newborn. What findings indicate the need for further evaluation? Select all that apply. a. asymmetrical fine jumping movement of the leg and arm muscles b. fanning and hyperextension of the toes when the soles is stroked upward from the heel c. grasping a finger placed in the neonate's palm d. muscle flaccidity not relieved by holding the newborn e. weak but effective sucking movements

a, d

The maternal-newborn nurse determines that which infant is at greatest risk for infection? a) 38 weeks' gestation, small for gestational age b) 39 weeks' gestation, diagnosed with caput succedaneum c) 38 weeks' gestation, cesarean delivery for breech presentation d) 41 week's gestation, infant of a diabetic mother

a) 38 weeks' gestation, small for gestational age

A parent brings a 3-year old child to the immunization clinic for DTaP vaccine. During the interview, the mother indicates the child is just finishing a tapered-dose of prednisone for a chronic respiratory problem. Which action should the nurse take at this time? a) delay the vaccine administration for 1 month after the medication is completed b) provide the child with the vaccine as scheduled c) cleanse the injection site with sterile saline instead of alcohol and administer the vaccine d) keep the child in the clinic for 30 minutes after administration to assess the child's response

a) delay the vaccine administration for 1 month after the medication is completed

Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome (RDS)? a) maintain a neutral thermal environment b) perform a complete gestational-age assessment c) perform chest physiotherapy twice a day d) suction meconium from airway as needed

a) maintain a neutral thermal environment

Which data would be most important for the nurse to note as part of an initial assessment of a newborn's history? a) mother received morphine sulfate 4 mg IV 20 minutes before delivery b) mother reports drinking a glass of wine with dinner each night c) mother's age is 14 d) mother's blood type is O negavtive

a) mother received morphine sulfate 4 mg IV 20 minutes before delivery

A neonatal nurse is attending a high-risk delivery and is told that the mother received morphin sulfate IV 30 minutes ago. The nurse should prepared to give which medication to the infant immediately after delivery? a) naloxone b) regular insulin c) double dose of vitamin K d) magnesium sulfate

a) naloxone

A 9-year-old client is brought to the pediatrician's office for a varicella virus vaccine. Before preparing the dose of the vaccine, the nurse would determine the child's status regarding what health history item? a) recent blood product transfusion b) allergy to milk c) allergy to penicillin d) history of splenectomy

a) recent blood transfusion

The mother of a child who has been exposed to chickenpox telephone the pediatric clinic for advice. The triage nurse asks about which of the following before responding to the mother's request for information? a) the child's exposure and immune status b) whether the child has had a rubella vaccination c) the age, height, and weight of the child d) the relationship of the person to whom the child was exposed

a) the child's exposure and immune status

A 2-month-old client is seen in the pediatric clinic for a well-baby checkup. The nurse anticipates which routine immunizations will be administered at this time? Select all that apply. a) IPV b) DTaP c) Hib d) MMR e) varicella

a, b, c

The mother of a 15-month-old child is anxious the immunizations her child is about to receive. What information should the nurse provide to the mother about immunizations? Select all that apply. a) possible localized reaction b) administration of acetaminophen as needed after vaccine administration c) informed consent or refusal form for mother to sign d) administration of aspirin every 4 hours post-vaccine administration e) symptoms of anaphylaxis reaction with immediate access to emergency care

a, b, c, e

What should the nurse tell a mother whose child is receiving the immunizations required at 1 year of age? Select all that apply. a) you can give your child acetaminophen if he develops a mild fever. b) we give all these immunizations at the same time because they are more effective if given together. c) you can expect your child not to feel well for a couple of days. d) some children develop itching or a rash after immunizations are given. This can be treated at home with an antihistamine.

a, d

The nurse concludes that a postpartum client is using appropriate bottle-feeding technique after observing which behavior? Select all that apply. a. keeps the nipple full of formula throughout the feeding b. props the bottle on a rolled towel c. points the bottle at the infant's tongue d. enlarges the nipple hole to allow for a steady stream of formula to flow e. keeps the infant close with head elevated

a, e

When planning client instruction on breastfeeding, the nurse should include that the amount of breastmilk the mother produces is directly related to which factor? a. her newborn's sucking stimulus b. her breast size c. her newborn's weight d. her nipple erectility

a. her newborn's sucking stimulus Rationale: prolactin and oxytocin, two hormones necessary for breast milk production and letdown, are released from the stimulus of the newborn suckling.

A 6-hour-old infant passes an unformed, black, tarlike stool. What conclsuion should the nurse draw from this finding? a. it is meconium stool that is expected at this time. b. it is meconium stool expected at the time of birth. c. it is a transitional stool expected at this time. d. it is a transitional stool that is expected later.

a. it is meconium stool that is expected at this time.

A newborn's father expresses concern that his baby does not have good control of his hands and arms. The nurse should explain which concept in response to the client, using wording that the client can understand? a. neurologic function progresses in a head-to-toe, proximal-to-distal fashion b. purposeful, uncoordinated movements of the arms are abnormal c. mild hypotonia is expected in the upper extremities d. asymmetric muscle tone is not unusual

a. neurologic function progresses in a head-to-toe, proximal-to-distal fashion Rationale: The newborn body grows in a head-to-toe and proximal-to-distal fashion.

The nurse observes that when a newborn is supine and the head is turned to one side, the extremities straighten to that side while the opposite extremities flex. How should the nurse document this finding? a. tonic neck reflex b. moro reflex c. cremasteric reflex d. babinski reflex

a. tonic neck reflex Rationale: the tonic neck reflex, or fencing position, refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side will extend, and the opposite extremities will flex.

In providing guidelines to follow when using concentrated formula for bottle-feeding, the nurse should give which instruction to new parents? a. wash the top of the can and can opener with soap and water before opening the can. b. adjust the amount of water added according to the weight gain pattern of the newborn. c. make sure the newborn takes all the formula measured into each bottle. d. warm the formula in a microwave oven for a few minutes before feeding.

a. wash the top of the can and can opener with soap and water before opening the can. Rationale: The top of the can and can opener should be washed to remove microorganisms.

Contraindications for IPV vaccine

allergies to formalin, neomycin, streptomycin, or polymyxin B, anaphylactic reaction, moderately or severely ill at time of vaccination (minor illness or cold can be vaccinated)

Contraindications for MMR

allergy to neomycin, gelatin, or eggs severely impaired immune system Avoid administering during pregnancy

A 26-week gestation neonate has received 80-100% oxygen via mechanical ventilation for 2 weeks and has received several blood transfusions for anemia The nurse should plan for which intervention needed by the infant? a) begin phototherapy b) arrange for eye exam by ophthalmologist prior to discharge c) wean supplemental oxygen rapidly d) administer surfactant via endotracheal tube

b) arrange for an eye exam by ophthalmologist prior to discharge Rationale: Receiving high levels of oxygen can put infants at risk for retinopathy of prematurity.

The nurse has an order to give an infant a dose of IPV vaccine. The nurse would take which action before administering the medication to ensure the dose is safe and effective? a) take dose that has not expired from a box on the shelf in the medication room b) assess prior to dose for allergy to neomycin, streptomycin, or polymixin B c) gently agitate the cloudy white solution before drawing up d) select a proper-sized muscle for injection

b) assess prior dose for allergy to neomycin, streptomycin, or polymixin B

While observing parents whose newborn is in the neonatal intensive care unit, the nurse interprets that teaching has been effective when the parents perform which activity? a) wear gloves every time they touch their baby b) attach family pictures to the side of the isolette c) bring a 2-year-old sibling to visit d) turn off the cardiac monitor at the newborn's bedside

b) attach family pictures to the side of the isolette

A nurse preparing to draw up a dose of vaccine notices that a vial of DTaP vaccine on the countertop does not have a date recorded for when it was opened. What action should the nurse take? a) use the vaccine but explain to the caregiver that the site may be quite tender b) discard the vaccine according to agency's policy c) contact the supervisor because this is reportable to the state Board of Public Health d) use the vaccine just for the day and then discard it

b) discard the vaccine according to agency's policy

A nurse working in an immunization clinic ensures at the beginning of each workday that which priority medication is available and within the expiration date? a) lidocaine b) epinephrine c) acetaminophen d) Ibuprofen

b) epinephrine

While feeding an infant, the nurse notices white, adherent patches on the infant's gums and buccal cavity. Which action should the nurse take at this time? a) document this normal finding b) further evaluate for yeast infection c) verify that vitamin K was given at delivery d) assess for maternal history of herpes simplex

b) further evaluate for yeast infection

The parents of a preterm neonate ask why their baby gets cold so easily. The nurse responds with which explanation about preterm newborns? a) able to shiver to produce body heat b) have minimal body fat to retain body heat c) have blood vessels that are deep under the skin surface d) lose heat faster because they lie in a fetal position

b) have minimal body fat to retain body heat

The nurse hears the parents of a 26-week gestation newborn tell family members, "We'll be ready to bring the baby home in a few weeks." What is the most therapeutic response by the nurse? a) I'm glad he's doing so well b) He probably won't be ready to come home for a few months c) A therapist could help you resolve your feelings of denial d) Do you have the nursery ready yet?

b) he probably won't be ready to go home for a few months

The pediatric clinic nurse has just administered a dose of Hib vaccine to a child. The nurse explains to the parents that they can expect which type of local reaction following the injection? a) mild to moderate fever b) pain or redness at site c) irritability d) decreased appetite

b) pain or redness at site

A child stepped on a rusty nail and is brought to the emergency department. The child's electronic health record indicates the child has not been adequately immunized against tetanus according to the immunization schedule. What would the emergency department nurse expect to be ordered for this child? a) diphtheria, tetanus, and pertussis vaccine b) tetanus immune globulin c) a broad spectrum antibiotic d) tetanus toxoid

b) tetanus immune globulin

A newborn is receiving phototherapy for the treatment of hyperbilirubinemia. The nurse evaluates that teaching has been effective when the parents demonstrate which behavior? Select all that apply. a) cover the infant with a loose blanket while under the bililight b) continue breastfeeding during the jaundice c) cover the infant's eyes before placing him under the bililight d) keep the genitalia covered to prevent soiling

b, c, d

The pediatric nurse is seeing a 2-month-old infant in the outpatient clinic for routine immunizations. The nurse should select which immunization teaching sheets to give to the mother before preparing the immunizations appropriate for this visit? Select all that apply. a) varicella b) DTaP c) MMR d) Hib e) IPV

b, d, e

A postpartum client is bottle-feeding her newborn. What should the nurse teach the client about regurgitation of small amounts of formula? Select all that apply. a. take a rectal temperature to check for fever b. recognize this as a normal occurrence c. discontinue feedings for 6-8 hours d. report this promptly to the healthcare provider e. understand that this may result from overfeeding

b, e

The nurse assesses a newborn and obtains the following information: Left arm limp and extended; left hand internally rotated; positive grasp reflex bilaterally; no response on left side to Moro reflex. What is the most appropriate nursing intervention for this infant? Select all that apply. a) assess for congenital hip dyspasia b) avoid positioning infant on left side c) provide passive range of motion exercises after 24 hours d) prepare supplies for a cast application e) immobilize the arm by securing the infant's sleeve to the shirt

b, e

A new mother overhears a nurse mention "first period of reactivity" and asks the nurse for an explanation of the term. Which statement would be best to include in a response? a. "the period begins when the infant awakens from a deep sleep." b. "the period is an excellent time to acquaint the parents with the newborn." c. "the period is an excellent time for the mother to sleep and recover from labor and delivery." d. "the period ends when the amount of respiratory mucus has decreased."

b. "the period is an excellent time to acquaint the parents with the newborn." Rationale: The first period of reactivity last up to 30 minutes after birth.

A new mother who is breast-feeding her infant asks the nurse, "What kind of stools will my baby have, and how many will there be during the next month?" What would be the best response by the nurse? a. one or two well-formed yellow-orange stools per day b. as many as 6-10 small, loos, yellow stools per day c. a well-formed brown stool at least every other day d. frequent loose, green stools

b. as many as 6-10 small, loos, yellow stools per day Rationale: Breastfed infants will have 6-10 small, loose yellow stools per day during the first few months.

When caring for a newborn, the nurse must be alert for what potential sign of cold stress? a. decreased activity level b. increased respiratory rate c. hyperglycemia d. shivering

b. increased respiratory rate Rationale: When an infant is stressed by cold, oxygen consumption increases, and the increased respiratory rate is a response to the need of oxygen.

Which action by a new postpartum client indicates to the nurse the need for further instruction in breastfeeding technique? a. holds the breast with four fingers along the bottom and thumb on top b. leans forward to bring her breast toward the baby c. stimulates the rooting reflex, then inserts the nipple and areola into the newborn's mouth d. checks the placement of the newborn's tongue before breastfeeding

b. leans forward to bring her breast toward the baby Rationale: The newborn should be brought to the breast, not the breast to the newborn; therefore, the mother would need further demonstration and teaching to correct this ineffective action.

During a physical assessment, the nurse palpates the newborn's hard and soft palate with a gloved index finger. The infant's mother asks the nurse to explain what is being done. The nurse replies that this assessment is done to detect which possible problem? a. shortened frenulum b. openings in the palate c. thrush infection d. adequacy of saliva production

b. openings in the palate Rationale: The hard and soft palates are examined to feel for any openings, or clefts.

A 10-month old infant is admitted to the emergency department with a 102℉ (38.9℃) rectal temperature and a history of vomiting and diarrhea for 48 hours. For which signs should the nurse assess? a. bulging fontanels, tearless cry, and low urine output b. sunken eyes, lethargy, and dry, furrowed tongue c. weight loss, dilute urine, and peripheral edema d. dry skin, thready pulse, and neck vein distention

b. sunken eyes, lethargy, and dry, furrowed tongue Rationale: The client's history suggest dehydration.

The nurse anticipates that a newborn male, estimated to be 39 weeks' gestation, should exhibit which characteristics? a. extended posture when at rest b. testes descended into the scrotum c. abundant lanugo over his entire body d. the ability to move his elbow past his sternum

b. testes descended into the scrotum Rationale: A full-term male infant will have both testes in his scrotum, with rugae present.

The neonatal nurse is providing anticipatory guidance to the mother of a newborn infant. When discussing immunization schedules, the nurse explain that the first dose of IPV is given at what age? a) 1 week b) 1 month c) 2 months d) 4 months

c) 2 months

A 6-year-old child with asplenia is receiving the meningococcal vaccine. The nurse explains to the child's mother that the vaccine should be effective for how many years? a) 1 b) 2 c) 5 d) 10

c) 5

The nurse is making client assignments for the shift. Which baby could be appropriately assigned to an LPN/LVN? a) an infant being admitted with hypoglycemia b) an infant scheduled to receive blood this shift c) a stable premature infant being fed every 2 hours d) an infant with rising bilirubin levels

c) a stable premature infant being fed every 2 hours

A child is brought to the pediatric ambulatory clinic with a runny nose and low-grade fever. He is scheduled to receive the MMR and DTaP vaccines. What should the nurse do at this time? a) get special permission from the healthcare provider to administer the vaccine b) defer both vaccines until the child is well c) administer the vaccines as scheduled d) administer the DTaP vaccine but defer the MMR

c) administer the vaccines as scheduled

A mother brings her infant to the immunization clinic for the final Hep B vaccine. After picking up the vial of vaccine to draw up the dose, the nurse notes that it is cloudy. What action should the nurse take? a) warm the vaccine under warm water b) discard the vaccine and contact the supplier of the vaccine c) agitate the vital gently and draw up the vaccine d) calculate the pediatric dose, since it is intended for adult use

c) agitate the vial gently and draw up the vaccine Rationale: it is normal for the Hep B to be cloudy

A nurse is preparing to draw up a dose of Hib vaccine for a pediatric client. The nurse concludes that the vial is acceptable to use after noting which expected coloration of the fluid in the vial? a) pale yellow b) light pink c) clear d) brown tinged

c) clear

The nurse is caring for a neonate born to a mother who is HIV positive. Which sign in the newborn should be evaluated further? a) absent tears b) white bumps on nose c) enlarged liver d) fine, red rash over trunk

c) enlarged liver Rationale: Hepatosplenomegaly ( enlarged liver and spleen) can be an early sign of HIV infection in an infant.

A pediatric client is scheduled to receive a dose of MMR vaccine. The nurse would question the order to give the dose at this time if which data was obtained during the short intake history? a) recent upper respiratory infection b) weight loss of 3 pounds during the last month c) history of allergy to neomycin or gelatin d) local reaction to previous dose

c) history of allergy to neomycin or gelatin

The nurse is developing a plan of care for an infant born at 28-weeks gestation. What would be a realistic goal for this infant to achieve within 1 week? a) drinking from a bottle b) recognizing the parents c) maintaining respiratory rate at 30-60 breaths/min d) maintaining body temperature in a bassinet

c) maintaining respiratory rate at 30-60 breaths/min

The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn? a) a neonate with a sustained heart rate of 118 beats/min b) a neonate with an axillary temperature of 97.5 c) a neonate with a sustained respiratory rate of 68 breaths/min d) a neonate who is small for gestational age

c) respiratory rate of 68 beats/min

A father asks how the bilirubin lights make the newborn's bilirubin level go down. What is the best reply by the nurse? a) the lights prevent more bilirubin from being released into your baby's body b) exposing the skin to the air helps get rid of the jaundice. The bililights really just keep the baby warm while this occurs. c) the bililights help convert the bilirubin to a form the baby can get rid of d) the bililights release a substance in the body that attacks the bilirubin and destroys it

c) the bililights help convert the bilirubin to a form the baby can get rid of

During a physical exam of a newborn with developmental hip dysplasia, which assessment findings should the nurse expect to obtain? Select all that apply. a. symmetrical gluteal folds b. limited adduction of the affected leg c. absent femoral pulse when the hip is flexed and the leg is abducted d. limited abduction of the affected leg e. asymmetrical gluteal folds

c, d, e

Which suggestion should the nurse make to the mother of a breastfeeding newborn as the best treatment for physiologic jaundice? a. switching permanently to formula b. giving supplement water feedings c. increasing frequency of breastfeeding sessions d. feeding the newborn nothing by mouth

c. increasing frequency of breastfeeding sessions Rationale: Physiologic jaundice is best treated by more frequent feedings to increase stooling and the excretion of bilirubin.

Which physical assessment finding should the nurse record as part of a newborn's gestational age assessment? a. umbilical cord moist to touch b. anterior and posterior fontanels non-bulging c. plantar creases present on anterior two-thirds of sole d. milia present on bridge of nose

c. plantar creases present on anterior two-thirds of sole Rationale: plantar creases are part of the physical maturity rating on the gestational age assessment.

Swelling of soft tissue under scalp that subside within a few days

caput succedaneum

Physical characteristic for a premature neonate.

color (pink or ruddy may show acrocyanosis) skin (reddened & transulent, blood vessels are readily apparent) Langugo (plentiful & widely distributed) Head size (appears large in relation to the body) Skull bones (pliable; fontanel is smooth & flat) Ears (minimal cartliage & pliable, folded over) Nails (soft & short) Testes ( may not be descended & scrotum nonrugated) Clitoris & labia minora ( prominent) Resting position (flaccid, frog-like) Cry ( weak & feeble) Reflexes ( sucking, swallowing, & gag are poor) Activity ( jerky, generalized movement, seizure activity is abnormal)

A child with cardia disease is recommended to receive the yearly influenza vaccine. The nurse would schedule the child to receive the vaccine at the routine visit scheduled in which month? a) January b) April c) July d) October

d) October

An infant of a diabetic mother (IDM) is admitted to the newborn nursery. Which nursing intervention has highest priority at this time? a) clean the umbilical cord b) administer vitamin K intramuscularly c) complete a gestational-age assessment d) assess the infant's blood glucose level

d) assess the infant's blood glucose level

A newborn male is admitted to the nursery 15 minutes after delivery. His skin is mottled and mucous membranes are blue; he is active and is wrapped in a blanket The nurse should make which assessment as a priority? a) umbilical cord for bleeding b) infant's temperature c) visible deformities d) patent airway

d) patent airway

A pediatric client has received a dose of PCV. The nurse evaluates that the parents understand postvaccination instructions if they state that which symptom is most important to report promptly to the healthcare provider? a) mild fever b) drowsiness c) decreased appetite d) rash with hives

d) rash with hives

An infant with fetal alcohol spectrum disorder is about to be discharged home with foster parents. Place in order the priority of the nurse in teaching the following topics to the foster parents. a) toy safety b) infection prevention c) feeding methods d) immunizations

d, c, b, a

Which assessment data would alert the nurse that a newborn infant is experiencing dehydration? Select all that apply. a) urine-specific gravity 1.006 b) urine volume 2 mL/kg/hr c) low serum sodium d) sunken anterior fontanel e) poor skin tugor

d, e

A mother is anxious about her newborn. She asks the nurse why there are no tears when her baby is crying. The nurse's response incorporates an understanding of which concept? a. the lacrimal ducts must be punctured to initiate tear flow b. antibiotic instillation at birth reduces tear formation for several days c. exposure to rubella in utero can result in lacrimal duct stenosis d. lacrimal ducts are nonfunctional until 2 months of age

d. lacrimal ducts are nonfunctional until 2 months of age Rationale: The cry of the newborn is tearless because the lacrimal ducts are not usually functioning until the second month of life.

If a newborn does not pass meconium during the first 36 hours of life, what is the priority action by the nurse? a. observe the anal area for fissures b. notify the healthcare provider c. increase the amount of oral feedings d. measure the abdominal girth

d. measure the abdominal girth Rationale: The first meconium stool should be passed within 24 hours after birth; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction.

Following delivery, the nurse should first assess which two newborn body systems that must undergo the most rapid changes to support extrauterine life? a. gastrointestinal and hepatic b. urinary and hematologic c. neurologic and temperature control d. respiratory and cardiovascular

d. respiratory and cardiovascular Rationale: To begin life the infant must make the adaption to establish respirations and circulation. These two changes are crucial to life.

Contraindication of PCV

hypersensitivity to diphtheria toxoid or severe illness and anaphylaxis to previous dose

rooting reflex

infant turns to side stimulated and opens mouth to suck

Infectious and communicable diseases in children that are vaccine-preventable (a live vaccine; attenuated vaccine)

measles (rubeola), mumps (parotitis), rubella (German measles) MMR

Common side effects to Hep B

pain or redness at injection site; fever; headache, photophobia, elevated liver enzymes Rare Side Effect: anaphylaxis

Epstein's pearls

small white specks, iclusion cysts, on gum ridges

Tonic neck reflex (fencer position)

when head turned to one side, extremities on same side extend and extremities on opposite side flex

sucking reflex

when object placed in mouth or touches lips