306 Ricci PrepU Chapter 18: Nursing Management of the Newborn

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. 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.

Which technique(s) will the nurse use when administering an intramuscular (IM) injection to a term neonate? Select all that apply.

Stabilizing the needle with the nondominant hand Using a quick darting motion Injecting slowly into the anterolateral thigh Stabilizing the needle with the nondominant hand Using a quick darting motion Injecting slowly into the anterolateral thigh

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. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

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" Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.

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 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.

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 Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students.

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 initial bath for a newborn is done using warm water, a mild soap (not hexachlorophene, which can be absorbed through the skin), and a thermometer to check the newborn's temperature following the bath. Talc powder is not recommended because of the risk for aspiration.

A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment?

blood pressure Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.

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 skin to skin (kangaroo) care The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?

obtain a transcutaneous bilirubin test Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice.

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 Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

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 identification bands warmer beds 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.

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 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.

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 One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

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 Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed.

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 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.

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 of the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

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 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.

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 the mother Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

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 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 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 to provide skin to skin (kangaroo) care The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

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

intramuscularly The American Academy of Pediatrics recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a one month period. It is not given subcutaneously or intravenously.

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 This most likely is erythema toxicum, also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment. This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection.

A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply.

lanugo genitals Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals. Arm recoil, posture, and the scarf sign are used to evaluate neuromuscular maturity.

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 Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.

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 while sleeping It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

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 both with a blanket Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

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 foreskin in male newborns does not normally retract and should not be forced. The nurse will inspect the genital area for irritated skin to prevent and/or treat possible skin irritations. The nurse will palpate the testes to determine if the newborn has cryptorchidism. It is important to verify that the urethral opening is at the tip of the glans and not on the dorsal or ventral sides as these would need intervention. This can be accomplished without overmanipulating the foreskin.

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?

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.

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 A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

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." 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, does not help prevent ophthalmia neonatorum, or strengthen the immune system.

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." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

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" 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 or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

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 because he might be too full" Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. 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.

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." Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. 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.

A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.

24 Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml.

What is the expected range for respirations in a newborn?

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 nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.

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. Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply.

Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn. By preventing hypothermia in a newborn, the chance of hypoglycemia is lessened since cold stress causes a newborn to burn more calories. Feedings should also begin early, with either breast milk or formula. Glucose water does not provide enough glucose for the newborn. Skin-to-skin (kangaroo) care keeps the newborn in a thermoneutral environment.

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. 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.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply.

Jitteriness Lethargy Seizures Signs and symptoms of hypoglycemia in newborns can include jitteriness, lethargy, cyanosis, apnea, high-pitched or weak cry, hypothermia, and poor feeding. Respiratory distress, apnea, seizures, and coma are late signs of hypoglycemia. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur.

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 notes on the left upper outer thigh A 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.

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.

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. Do not remove the identification bands until the newborn is discharged from the hospital. 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.

A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used.

Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate. Commonly the first step in a nursing intervention cascade is assessment. However, the nurse already has assessed that the newborn is term, is not crying, and has decreased tone that would require intervention. The first step is to warm the newborn and then to decrease any further loss of heat through evaporation by drying the newborn. The airway should be cleared before the newborn is stimulated to avoid aspiration. The nurse would then check the heart rate to see if further resuscitation efforts are necessary.

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 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 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's hospital identification badge The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take?

assess the bilirubin level If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time.

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 To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her 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?

breastfeed the newborn 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 0.66 oz to 1 oz (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 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 asking questions Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge.

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?

erythema toxicum 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.

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

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 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.

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 Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.

The Apgar score is based on which 5 parameters?

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

identify the newborn The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.

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 newborns heart rate over the anterior fontanel Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn.

The Ballard scoring system evaluates newborns on which two factors?

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

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 blankets while obtaining diapers The nurse will cover the newborn to maintain temperature and place the infant in the bassinet while obtaining more diapers. The nurse would not leave to newborn on the scales and walk away, because the newborn could fall off the scale. Current policy prevents the nurse from carrying the newborn while going to the supply closet to obtain more diapers because this is a fall risk or safety issue. Infection control measures dictate that there is no sharing of supplies between newborns.

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 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.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

the infant is experiencing moderate difficult adjusting to extrauterine life The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 7 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.

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?

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.