Ch 31 Care of the Newborn

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. bring the infant to the clinic 2. this is a normal occurrence and no further action is needed 3. increase the number of times that the cord is cleaned per day 4. monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues

1. bring the infant to the clinic

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. cyanosis 2. tachypnea 3. hypotension 4. retractions 5. audible grunts 6. presence of a barrel chest

1. cyanosis 2. tachypnea 4. retractions 5. audible grunts

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. length of 19 inches 2. abnormal palmar creases 3. birth weight of 6 lb 14 oz (3120 g) 4. head circumference appropriate for gestational age

2. abnormal palmar creases

The nurse in a NICU receives a telephone call to prepare for admission of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. turn on the apnea and cardiorespiratory monitors 2. connect the resuscitation bag to the oxygen outlet 3. set up the intravenous line with 5% dextrose in water 4. set the radiant warmer control temperature at 36.5 C (97.6 F)

2. connect the resuscitation bag to the oxygen outlet

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which instruction to the mother? 1. feed the newborn less frequently 2. continue to breast feed every 2 to 4 hours 3. switch to bottle feeding the infant for 2 weeks 4. stop breast feeding and switch to bottle feeding permanently

2. continue to breast feed every 2 to 4 hours

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. developmental delays because of excessive size 2. maintaining safety because of low blood glucose levels 3. choking because of impaired suck and swallow reflexes 4. elevated body temperature because of excess fat and glycogen

2. maintaining safety because of low blood glucose levels

The nurse creates a plan of care for a woman with HIV infection and her newborn. The nurse should include which intervention in the plan of care? 1. monitoring the newborn's vital signs routinely 2. maintaining standard precautions at all times while caring for the newborn 3. initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. instructing the breastfeeding mother regarding the treatment of the nipples with nystatin ointment

2. maintaining standard precautions at all times while caring for the newborn

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "i will place my baby's crib close to the door" 2. "some health care personnel won't have name badges" 3. "i will ask the nurse to attend to my infant if i am napping and my husband is not here" 4. "its okay to allow the nurse assistant to carry my newborn to the nursery"

3. "i will ask the nurse to attend to my infant if i am napping and my husband is not here"

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. apply gentle pressure 2. reinforce the dressing 3. document the findings 4. contact the HCP

3. document the findings

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. warming the crib pad 2. closing the doors to the room 3. drying the infant with a warm blanket 4. turning on the overhead radiant warmer

3. drying the infant with a warm blanket

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "your newborn needs the medicine to develop immunity" 2. "the medicine will protect your newborn from being jaundiced" 3. "newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel" 4. "newborns are deficient in vitamin K, and this inject prevents your newborn from bleeding"

4. "newborns are deficient in vitamin K, and this inject prevents your newborn from bleeding"

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. avoid stimulation 2. decrease fluid intake 3. expose all of the newborn's skin 4. monitor skin temperature closely 5. reposition the newborn every 2 hours 6. cover the newborn's eyes with eye shields or patches

4. monitor skin temperature closely 5. reposition the newborn every 2 hours 6. cover the newborn's eyes with eye shields or patches

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. lethargy 2. sleepiness 3. irritability 4. constant crying 5. difficult to comfort 6. cuddles when being held

3. irritability 4. constant crying 5. difficult to comfort

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. allow the newborn to establish own sleep-rest pattern 2. maintain the newborn in a brightly lit area of the nursery 3. encourage frequent handling of the newborn by staff and parents 4. monitor the newborn's response to feedings and weight gain pattern

4. monitor the newborn's response to feedings and weight gain pattern

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. protects the newborn's eyes from possible infections acquired while hospitalized 2. prevents cataracts in the newborn born to a woman who is susceptible to rubella 3. minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. prevents an infection called opthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

4. prevents an infection called opthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection