Prep U ch 18

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

Which of the following describes a chromosome aberration?

Short stature, webbed neck

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?

scalp edema

Assisting in the initiation of breast-feeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding?

Within the first 30 minutes after birth

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 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 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?

Blood Pressure

The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?

Conduction

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

Document this as pseudo menstruation

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek.

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform?

Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?

Help the mother provide kangaroo care.

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

Instruct the mom to feed every two to three hours.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman?

It is a normal skin finding in a newborn."

During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby?

Low-set ears

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?

Mongolian spot noted on left upper outer thigh.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus.

Under which circumstances should gloves be worn in the newborn nursery?

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

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

Retracting the foreskin over the glans to assess for secretions

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

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

an extrusion reflex at 9 months of age

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice?

bilirubin hyperexcretion

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

caput succedaneum

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:

caput succedaneum

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as:

erythema toxicum.

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

hypothermia

Which factors could increase the risk of overheating in a newborn? Select all that apply

limited ability of diaphoresis isolette that is too warm

The goal of eye prophylaxis is to:

prevent ophthalmia neonatorum.

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

radiation, convection, and conduction

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?

reflex

At what point should the nurse expect a healthy newborn to pass meconium

within 24 hours after birth

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery

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 new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

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 2-3 hours on demand

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum

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.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?

Demonstrating how to do cord care on the newborn

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply

Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination. Bathe the newborn thoroughly.

A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?

He should wet between 6 to 10 diapers each day.

The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply.

Hepatitis B vaccination Hepatitis B immune globulin

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?

Hip for dislocation

Which assessment finding indicates to the nurse that a newborn has hip subluxation?

Inability of the right hip to abduct

The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action?

Infant C - 48 mg/dL

A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity?

Moro reflex

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize?

Move the infant away from the window.

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?

No action is need; this is normal.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed

No interventions are needed. This will resolve on its own over the next several days

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?

Physiologic jaundice.

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 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

he nurse is teaching discharge instructions to the young parents of a healthy newborn boy whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

Redness at the base of the umbilical cord

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?

The breakdown of RBCs release bilirubin, which the liver cannot excrete

A young male client asks the nurse about circumcision, since he was never circumcised as an infant. Which rationale would be appropriate for exploring circumcision in an adult male?

The client has experienced recurring balanoposthitis and phimosis

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.

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?

Vernix

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

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

A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.

"I understand your concern because as many as 50% of babies can develop jaundice.

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching?

"The rate of penile cancer is less for circumcised males."

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 will turn the mobile on that's hanging on our baby's crib."

A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?

"Wrapping the newborn too tightly can impair breathing."

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?

5% to 10% of their birth weight

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel will close. Which time span is the normal duration for the closure of the posterior fontanel?

8 to 12 weeks

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer.

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?

Be consistently attentive to the infant's basic needs.

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase?

Cardiopulmonary

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching?

Feed the newborn on demand or at least every 2 to 4 hours during the day. Burp the newborn frequently throughout each feeding. Use feeding time for promoting closeness.

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

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother.

The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best?

Inform the practitioner and cancel the procedure.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed?

No interventions are needed. This will resolve on its own over the next several days

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse?

Notify the charge nurse, because it represents a possible complication, and document the finding.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how he or she is turned.

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

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

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement?

Quiet alert

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

Rewarm the newborn gradually.

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?

Some women just can't breastfeed. Maybe I'm one of these women.

The nurse is assessing a 1-month-old male infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski's sign?

Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe

A woman has just given birth vaginally to a newborn. Which action will the nurse do first?

Suction the mouth and nose.

Which factor might result in a decreased supply of breast milk in a postpartum client

Supplemental feedings with formula

Which factor might result in a decreased supply of breast milk in a postpartum client?

Supplemental feedings with formula

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?

The infant is attempting self-consoling maneuvers.

A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make?

Try swaddling her nice and snuggly." "Try shushing her loudly." "Encourage her to suck."

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

New parents are getting ready to go home and have received information to help them learn how best to care for the 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 nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?

brown fat

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply.

cephalohematoma molding caput succedaneum

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect?

developmental dysplasia of the hip (DDH

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.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing

When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?

keeping it dry

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates

normal progression of behavior

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?

on admission to the nursery

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

two smaller arteries and one larger vein

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs

A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection?

working inside an isolette as much as possible.

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?

yellow sclera

The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect?

yellowish-brown, seedy stool