Nursing Management of the Newborn

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

"Always wash your hands before you pick up or provide care to your newborn."

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?

"I can use talc powders to prevent diaper rash."

The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate?

"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly."

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse?

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective?

"We'll turn the mobile on that's hanging above his head in his crib."

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range?

0.5 to 1.0 mg

What is the expected range for respirations in a newborn?

30 to 60 breaths per minute

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?

A female in her mid-20s who appears pregnant

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply.

A washcloth Warm tub of water Thermometer

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

A nurse is preparing to weigh a newborn just admitted to the nursery. Place the steps listed below in the order that the nurse would complete them. Use all options.

Balance the scale. Cover the scale with a warmed cloth. Recalibrate the scale to zero. Place the unclothed newborn in the center of the scale.

An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant?

Before feedings

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

Bradycardia

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

Breastfeed the infant every 2 to 4 hours on demand.

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions.

What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test?

Compare the identification bracelets prior to leaving the newborn with the mother.

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?

Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

Dry the newborn and place it skin-to-skin on mother.

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein pearls

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss

The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn.

A nurse suspects that a newborn is experiencing hypoglycemia based on assessment findings and obtains a heel stick to check the newborn's glucose level via a glucometer. Which action(s) is appropriate for the nurse to do when obtaining the specimen? Select all that apply.

Insert the lancet to a puncture depth of 2 mm. Wipe away the first drop of blood. Apply a pressure dressing to the puncture site when done.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

Look at the woman's hospital identification badge.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply.

Performing a heel stick Accucheck Changing a diaper Providing the first bath

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area.

A nurse removes and discards a newborn's diaper before placing the newborn on the scales for a daily weight. The nurse realizes there are no clean diapers at the scale. The supply closet is located down the hallway. What will the nurse do?

Place newborn in the bassinet and cover with blanket while obtaining diapers.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

Using a bulb syringe, suction the mouth then the nose.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Wear clean gloves.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign.

A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug:

intramuscularly.

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

A nurse is assessing a newborn's vital signs 2 hours after birth. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider?

pulse rate 100 bpm

The mother of a newborn asks the nurse, "What are these small red marks on the back of my baby's neck and between the eyes? They seem to more visible when my baby is crying." The nurse would describe this finding as which skin variation?

salmon patches

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often?

two or three times per week

Which statement is false regarding bathing the newborn?

The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full."

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman' hospital identification badge.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply.

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).

Which action will the nurse avoid when performing basic care for a newborn male?

Retracting the foreskin over the glans to assess for secretions

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

Place the infant on the back when sleeping.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?

Report the finding to the pediatrician.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

Warmer bed Suction equipment Identification bands

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation.

Which newborn neuromuscular system adaptation would the nurse not expect to find?

an extrusion reflex at 9 months of age

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn.