Nursing Care of the Newborn (Level 2)

A new mother is feeding her baby girl, who was born 36 hours ago in a spontaneous vaginal delivery. The nurse notices that the mother is crying and points to the top of her baby's head. She cries, "I don't know what's wrong with my baby! She didn't have this big lump on the right side of her head before now. I haven't dropped her! What happened to her?" What is the best response once the nurse has assessed the infant's head? "Your baby's head is just slightly elongated, and that's nothing to be concerned about." "She'll be examined again by the pediatrician before you leave later today, so there's no need to worry right now." "Your baby may have a condition called cephalhematoma. It's common, but I'll make a note to have the pediatrician assess it." "Your baby may have a condition called caput succedaneum, which is common. I'll make a note to have the pediatrician assess it."

"Your baby may have a condition called cephalhematoma. It's common, but I'll make a note to have the pediatrician assess it." A cephalhematoma usually develops on one side of the head over the parietal bones. The swelling is not generally present at birth; instead, it develops over the first 24 to 48 hours of life. Caput succedaneum appears over the vertex of the newborn's head and causes localized edema that varies in size. It is seen shortly after birth and resolves within 12 hours to several days after birth. Telling the mother not to worry dismisses her fears.

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy? Stimulates the liver to dispose of the bilirubin Breaks down the bilirubin into a conjugated form Facilitates the excretion of bilirubin by activating vitamin K Dissolves the bilirubin, allowing it to be excreted by the skin

Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.

During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition? Molding Hydrocephalus Cephalhematoma Caput succedaneum

Cephalhematoma Cephalhematoma is a collection of blood beneath the periosteum of the skull bone; the blood mass does not cross the suture line and is confined to one side of the head. It is reabsorbed within 3 to 6 weeks. Molding is overlapping of the cranial bones or shaping of the fetal head to accommodate and conform to the bony and soft parts of the mother's birth canal during labor; it resolves within 3 days. Hydrocephalus is an enlargement of the entire head (macrocephaly) caused by an abnormal enlargement of the cerebral ventricles and skull, which results from an obstruction in the flow of cerebral spinal fluid. Caput succedaneum is an edematous swelling of the scalp that extends across the suture line; it resolves within 3 to 4 days.

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points? Color: pale Respiratory rate: slow Reflex irritability: grimace Heart rate: 100 beats/min

Heart rate: 100 beats/min A heart rate of 100 beats/min or more is the only criterion that rates a 2 on the Apgar score. The pale color rates a 0. A slow respiratory rate or a weak cry rates a 1. A grimace after testing of reflex irritability rates a 1.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? Average for gestational age, term Small for gestational age, preterm Large for gestational age, postterm Large for gestational age, near term

Large for gestational age, near term Newborns of diabetic mothers may be large for gestational age because hyperglycemia in the mother precipitates hyperinsulinism in the fetus, resulting in excess deposits of fetal fat; these infants are usually born at or before term and are large, not average or small, for gestational age. Diabetic mothers with advanced vascular and renal disease may give birth to infants who are small for gestational age. Because of the risk for fetal death, women with diabetes should give birth before the 40th week of gestation, either by way of induction of labor or, if necessary, by cesarean birth.

During a newborn assessment a nurse identifies the absence of the red reflex in the eyes. The nurse should: Notify the primary health care provider. Rinse the eyes with sterile saline. Expect edema to subside within a few days. Conclude that this is a result of the prescribed eye prophylaxis.

Notify the primary health care provider. An absence of the red reflex may be indicative of congenital cataracts. The red reflex is elicited by shining the light of an ophthalmoscope into the newborn's eyes, which should produce a reddish circle. Rinsing the eyes will not affect the red reflex. The red reflex or its absence is not related to edema, which may occur after eye prophylaxis, or to eye prophylaxis itself.

A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility? A B O AB

O Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually are not a problem.

The mother of a newborn with exstrophy of the bladder tells the nurse that the primary health care provider said that her child may develop an unusual gait when learning to walk. What does the nurse tell the mother is the cause of waddling gait? Genu varum Tibial torsion Subluxation of the femur Separation of the pubic bones

Separation of the pubic bones The incomplete fetal bladder development may interfere with development of the pelvis. Genu varum (bowlegs) may be congenital or caused by rickets; the condition is not related to exstrophy of the bladder. Tibial torsion, a rotation of the tibia, is unrelated to exstrophy of the bladder. Subluxation of the femur, a form of hip dislocation, is unrelated to exstrophy of the bladder.

What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include? Examining for a cleft palate Testing for congenital syphilis Assessing the infant for muscle hypotonicity Inspecting the soles for maculopapular lesions

Testing for congenital syphilis Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be screened immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester; Treponema pallidum does not affect a fetus before the 16th week of gestation. Muscle hypotonicity is found in children with Down syndrome, not those with congenital syphilis. Maculopapular lesions of the soles do not manifest in the infant with congenital syphilis until about 3 months of age.

A nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify? Moro Babinski Tonic neck Palmar grasp

Tonic neck The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn that is present until the third month. The Moro reflex is exhibited when a sudden change in equilibrium causes extension and abduction of the extremities followed by flexion and adduction. The Babinski reflex is exhibited when the examiner runs a finger up the lateral (small toe side) undersurface of the foot from the heel to the toes and then across the ball of the foot; the toes separate and flare out in response. The palmar grasp reflex is exhibited when the fingers flex around a person's finger placed in the infant's palm.