Chapter 14: Nursing Care of the Normal Newborn Prep- U Maternal

The nurse is performing an assessment on a neonate. Which assessment finding should the nurse prioritize as suggestive of hypothermia?

Bradycardia

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?

Administer the medication into the anterolateral muscle.

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Administer vitamin K.

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.

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother?

This is a normal finding.

The nurse is providing care for a 10 lb, 2 oz newborn (4,590 g) who is three hours old. The infant begins to display signs of hypoglycemia. The nurse does a heel stick to obtain the infant's blood glucose level. At which of the following blood glucose levels would the nurse treat the infant for neonatal hypoglycemia?

blood glucose of 35 mg/dl (1.94 mmol/L)

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

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

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 is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

"Always wash your hands before you pick up or provide care to your newborn."

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.

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.

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."

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 mother.

A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?

"Place the newborn on the back to sleep and stomach to play."

The health care provider has ordered EMLA cream for an infant scheduled for a circumcision. What nursing action is priority?

Apply the cream one hour before the procedure

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.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes.

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

A new mother asks the nurse why her newborn must receive a vitamin K injection after birth. Which is the best response made by the nurse?

"It will decrease the risk of bleeding immediately after birth."

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."

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."

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

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?

Aspirate the oral and nasal pharynx with a bulb syringe.

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.

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.

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air.

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.

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.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure?

Monitor the site for bleeding.

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 when sleeping.

Which nursing intervention is priority for the nursery nurse to complete on a newborn immediately following a cesarean birth?

Suction the newborn's airway.

The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?

The newborn does not contract ophthalmia neonatorum.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.

There is a family history of hemophilia. The infant is at 33 weeks' gestation.

The nursery nurse appropriately identifies which nursing action as most appropriate to prevent neonatal infection?

handwashing

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

nasal flaring

The nurse is teaching a new mother how to handle and dress her newborn. Which of the following statements from the mother indicates that teaching was effective?

"I should hold my baby close to my body like I'm holding a football."

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 new mother asks the nurse why her newborn must get a vitamin K injection. Which response made by the nurse is best?

"Newborns need vitamin K to prevent hemorrhage. They cannot produce it themselves right after birth because of the lack of normal flora in their intestines."

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 nurse is teaching new parents about caring for their newborn's umbilical cord. The nurse determines that the teaching was successful based on which statement made by the parents?

"tt is important that we keep the area dry."

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range?

0.5 to 1.0 mg

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

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

The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame?

24 to 72 hours after birth.

An infant born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this infant?

Before feedings

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.

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 ask questions.

The experienced nurse notes a new graduate administering a hepatitis B vaccination to a newborn. What action by the new graduate will cause the experienced nurse to intervene?

Circularly cleaning the site, outward to inward.

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply.

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

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

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

Identify the newborn.

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose which best reason to prevent cold stress?

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range?

Injecting the medication into the vastus lateralis

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

The nurse is providing care for a 10 lb 2 oz. (4536 g) newborn who is 3 hours old. The infant is jittery, cool, has poor tone, and is not eating well. What will the nurse do next?

Obtain a blood glucose level.

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.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply.

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

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

Rewarm the newborn gradually.

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

The baby sleeps with the mother in bed.

Which statement is false regarding bathing the newborn?

The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

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.

The experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns?

Wearing artificial nails while caring for multiple newborns.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

Within one hour

One assessment parameter that the LPN/LVN is responsible for is fluid volume loss. It would be important to assess the umbilical cord for any sign of bleeding. What would be important to assess if the infant has an unusually large cord?

a loose clamp

In caring for the newborn the nurse recognizes that which finding is abnormal and will require immediate attention?

blood glucose level less than 40 mg per 100 ml of blood

A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options.

eyes face hair extremities diaper area

A nurse in the hospital is caring for a client at 37 weeks' gestation who experienced premature rupture of the membranes (PROM) more than 24 hours prior to coming to the hospital. The client presents with a fever of 100.4°F (38°C).

group B streptococcus administer intravenous antibiotics

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successful after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day