O' MEARA CHAPTER 18- THE NEWBORN

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? You Selected: 68 breaths per minute

Correct response: 68 breaths per minute Explanation: After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production?

Correct response: nonshivering thermogenesis Explanation: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect?

Correct response: pseudomenstruation, a normal finding Explanation: Pseudomenstruation is seen when a newborn female has a small amount of pinkish discharge. It comes from the withdrawal of maternal hormones and is a normal finding.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

You Selected: nonshivering thermogenesis Correct response: radiation, convection, and conduction Explanation: Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate?

Correct response: "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." Explanation: The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice associated with a blood incompatibility. Impaired bilirubin excretion, such as from an obstruction in the biliary tree, also can lead to jaundice. The causes of newborn jaundice are known; jaundice usually results from one of these three mechanisms.

A new mother who is breastfeeding her son asks the nurse, "How do I know if my son is getting enough fluids?" Which response by the nurse would be most appropriate?

Correct response: "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough." Explanation: Adequate fluid intake in a neonate is determined by the number of wet diapers or voidings he or she produces. On average, 6 to 8 voidings daily indicates adequate fluid intake. The neonate does not have a natural instinct to seek out additional fluid. Obtaining the necessary calories is important for weight gain, not fluid intake. There is no need to supplement feedings with additional water.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

Correct response: limited voluntary muscle activity Explanation: Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

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?

Correct response: "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." Explanation: A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding

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

Correct response: "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." Explanation: Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, prevent ophthalmia neonatorum, or strengthen the immune system.

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?

Correct response: "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." Explanation: The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

Correct response: Blood Pressure Explanation: The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

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?

Correct response: Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Explanation: A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? You Selected: Obtain a culture of the discharge.

Correct response: Document this as pseudo menstruation. Explanation: The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Correct response: Injecting the medication into the vastus lateralis Explanation: Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.

A newborn infant at 36 hours of age is jaundiced. The mother is breastfeeding. What intervention is appropriate to increase the excretion of bilirubin?

Correct response: Instruct the mom to feed every two to three hours. Explanation: Bilirubin is excreted in the urine and feces. Encouraging the mother to breastfeed at least every two to three hours will increase the waste and help decrease the bilirubin level. Stopping breastfeeding and administering glucose water for 24 hours would not be appropriate for the mother. Restricting feedings and giving glucose water every 4 to 6 hours is not an appropriate nursing intervention for an infant showing signs of jaundice. Keeping light away from the baby's skin does not help to clear jaundice; it could only make it worse.

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize?

Correct response: Move the infant away from the window. Explanation: The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.

A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range?

Correct response: Place the newborn skin-to-skin (kangaroo care) with the mother. Explanation: The nurse should place the newborn skin-to-skin (kangaroo care) with the mother. This is the best way to help maintain the newborn's temperature as well as promoting breastfeeding and bonding between the mother and newborn. The nurse can weigh the infant as long as a warmed cover is placed on the scale. The stethoscope should be warmed before it makes contact with the infant's skin, rather than using the stethoscope over the garment because it may obscure the reading. The newborn's crib should not be placed close to the outer walls in the room to prevent heat loss through radiation.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?

Correct response: The breakdown of RBCs release bilirubin, which the liver cannot excrete. Explanation: After birth, the newborn's hematocrit is about 45% to 65%, which is not needed after birth for oxygenation. The cells then die and are broken down, releasing bilirubin. The liver normally breaks down the bilirubin and eliminates it but since the liver is immature, it becomes overwhelmed and the bilirubin builds up in the bloodstream. Vitamin K levels have no effect on bilirubin levels. The immaturity of the GI tract does not cause the bilirubin to increase and feedings do not directly affect bilirubin levels.

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?

Correct response: The infant is attempting self-consoling maneuvers. Explanation: The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

Correct response: The tint is due to jaundice. Explanation: Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. It is not considered normal and does require assessment and intervention. Phototherapy is the recommended treatment of choice, not putting the child in sunlight. It is not a reaction to the vitamin K injection.

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:

Correct response: acrocyanosis. Explanation: Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Correct response: caput succedaneum. Explanation: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalohematoma is a localized effusion of blood beneath the periosteum of the skull.

A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition?

Correct response: erythema toxicum Explanation: Erythema toxicum is a rash of unknown cause, with pink papules and superimposed vesicles. It appears within 24 to 48 hours after birth and resolves spontaneously in a few days. Acrocyanosis is a blue color of the hands and feet appearing in most infants at birth. Acrocyanosis may persist for 7 to 10 days. Yeast is a fungal infection caused by Candida albicans; it usually manifests in the groin. The rash of C. albicans is excoriated and does not disappear without treatment. The presentation described in this scenario is not consistent with that of mumps.

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:

Correct response: milia. Explanation: Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. The harlequin sign refers to a transient phenomenon in which a newborn appears red on the dependent side of the body and pale on the upper side when lying on his or her side.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

Correct response: nasal flaring Explanation: Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?

Correct response: on admission to the nursery Explanation: Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

Correct response: respiratory and cardiovascular Explanation: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

Which sign would indicate dehydration in a newborn?

Correct response: sunken fontanels (fontanelles) Explanation: Sunken fontanels (fontanelles) in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

When assessing the newborn's umbilical cord, what should the nurse expect to find?

Correct response: two smaller arteries and one larger vein Explanation: When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

Correct response: vernix Explanation: Vernix is the coating on the infant that was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.