Prep U: Chapter 18: Nursing Management of the Newborn

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? milia stork bites Epstein's pearls Mongolian spots

Epstein's pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.

Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents? General questions about different aspects of newborn care Only questions specific to breast-feeding No questions of the nurse Confidence since they have another child already

General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? square window rooting posture popliteal angle

rooting The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.

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 once a week once a day every other day

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

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? Clean hands with a betadine scrub. Perform a 3-minute surgical-type scrub. Use infection transmission precautions. Wear clean gloves.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? "Change diapers frequently." "Give the newborn sponge baths until the umbilical cord falls off." "Daily tub baths are not necessary." "Use talc powders to prevent diaper rash."

"Use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Providing the first bath Taking the newborn's crib to the mother's room Feeding the newborn a bottle Performing a heel stick Accucheck Changing a diaper

Providing the first bath Performing a heel stick Accucheck Changing a diaper Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? Rocking and singing to her infant. Swaddling the infant Holding and cuddling the infant Use of mobiles above the crib.

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn? Infant throws arms outward and flexes knees. Infant's toes curl over the nurse's finger. Infant makes stepping motion. Toes fan out when sole of foot is stroked.

Toes fan out when sole of foot is stroked. The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.

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 any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Keep the newborn under the radiant heater when not with mom. Bathe and wash the newborn when temperature is 97.5° F (36.4° C)

Warm all surfaces and objects that come in contact with the newborn. The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill? Keeping the infant's cord clean and dry Washing their hands before handling the infant Rooming-in with their infant Using gloves when handling their infant

Washing their hands before handling the infant Hand washing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Rooming-in reduces the risk of cross-contamination but is not nearly as important as good hand washing.

The AGPAR score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

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 general fussiness approximately eight wet diapers a day

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? three arteries and no veins two arteries and two veins one artery and two veins two arteries and one vein

two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein.

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 turn the mobile on that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. Do not remove the identification bands until the newborn is discharged from the hospital. Don't leave the newborn unattended unless the mother is going to the bathroom. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery. Know when the newborn is scheduled for any tests and how long the procedure will last.

Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: thrush. milia. vernix caseosa. Epstein's pearls.

Epstein's pearls. Epstein's pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Evaporative Conductive Convective Radiating

Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Place the newborn's buttocks in warm water after each void or stool. Expose the newborn's bottom to air several times a day. Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area.

Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

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 recommendations would the nurse not make to this mother? Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant's back Feeding the infant more formula whenever she begins to fuss

Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant.

A nurse is changing a newborn's diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem? Go get another pack of diapers for the bassinet from the supply closet. Go to the next bassinet and take a diaper from that newborn's drawer. Tell the parents that their newborn needs more diapers. Go from bed to bed and locate some more diapers for the infant.

Go get another pack of diapers for the bassinet from the supply closet. Infection control measures dictate that there is no sharing of supplies between newborns, so the best choice would be to get another package of diapers for the newborn. Also, the parents are not responsible for diapers until after the newborn is discharged.

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K HiB Hep B HBV immunoglobin

Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 12 to 15. 7 to 10. 1 to 2.

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? Ineffective airway clearance related to mucus and secretions Altered nutrition less than body requirement related to limited formula intake Altered urinary elimination related to postcircumcision status Ineffective thermoregulation related to heat loss to the environment

Ineffective airway clearance related to mucus and secretions Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll place him on his belly on a blanket on the floor." "We'll hold off on feeding him for a while because he might be too full." "We'll vigorously rub his back as we play some music."

"We'll turn the mobile on that's hanging above his head in his crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? Protect the urethra from fecal material Prevent infection of the umbilical cord Protect tear ducts from vaginal bacteria Prevent infection of the eyes from vaginal bacteria

Prevent infection of the eyes from vaginal bacteria Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

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? "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should finish a bottle in less than 15 minutes." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed."

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

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "No, it is the tonic neck reflex. It signifies handedness."

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." "Circumcision is best in order to protect the baby from diseases like cancer." "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful."

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the primary care provider's responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents' signatures to a written documentation of that consent. If the parents have unanswered questions, the nurse should notify the care provider before the procedure is done.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents When the infant is 48 hours old Just before discharge home

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

What is the expected range for respirations in a newborn? 20 to 40 breaths per minute 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

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? Fewer complications than if done later in life Anesthetic may not be effective during the procedure Lower rate of urinary tract infections Reduced risk of penile cancer

Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge

After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment? Allow the newborn opportunities to self-soothe by crying himself to sleep. Place the infant in an open crib to allow freedom of movement. Be attentive to the basic needs of the infant and be consistent. Have the parents place the infant on a schedule as soon as possible.

Be attentive to the basic needs of the infant and be consistent. To enhance an infant's organization and develop a sense of trust, parents need to consistently meet the infant's needs through feedings, holding him and keeping him dry. Swaddling, not allowing freedom of movement, also helps the infant feel secure. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his needs.

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? Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand.

Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is .66 to 1 ounce (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

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. Notify the primary care provider if it appears red and sore. Cleanse the glans daily with alcohol. Soak the penis daily in warm water.

Cover the glans generously with petroleum jelly. Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting the medication into the vastus lateralis Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle

Injecting the medication into the vastus lateralis 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's of medication at a 90-degree angle.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic tetracycline.

Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? Moro tonic neck rooting fencing

Moro The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. They question the nurse concerning sleeping patterns for the newborn once they get home. What advice can the nurse provide for them? Place the infant on his abdomen or side to encourage sleep. If the infant continues to wake up at night after a few months, offer rice cereal before going to bed. Expect the infant to sleep through the night by 2 months of age. Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session.

Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session. Normally, newborns sleep 16 to 20 hours per day. Timing for sleeping through the night varies from infant to infant and should not be predicted to parents. Infants are always placed on their backs to sleep to reduce the risk of SIDS. Giving an infant solids earlier than 6 months is not helpful in encouraging them to sleep through the night and may upset their digestive tract.

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. Observe respiratory status frequently. Massage the newborn's back. Provide warm water to drink. Ensure the newborn's warmth. Provide oxygen supplementation.

Observe respiratory status frequently. Ensure the newborn's warmth. Provide oxygen supplementation. The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

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? Tape electronic thermistor probe to the abdominal skin. Obtain the temperature rectally. Obtain the temperature orally. Place electronic temperature probe in the midaxillary area.

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

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. Suction equipment Glucose water Identification bands Warmer bed Ophthalmoscope

Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

Which statement is false regarding bathing the newborn? Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face. 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. While bathing the newborn, the nurse should wear gloves.

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. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

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? Apgar score heart rate blood sugar temperature

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).

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? an immature autoregulation of blood flow concentration of immature blood vessels bruising from the birth process an allergic reaction to the soap used for the first bath

concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

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: stork bites. Mongolian spots. harlequin sign. erythema toxic.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

The Ballard scoring system evaluates newborns on which two factors? body maturity and cranial nerve maturity physical maturity and neuromuscular maturity tone maturity and extremities maturity skin maturity and reflex maturity

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? tonic neck sucking Moro rooting

rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.

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 prior to the newborn being discharged 24 hours after the newborn's birth within 30 minutes after birth, in the birthing area

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.