Chapter 18

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." "Be sure to keep the newborn's umbilical cord stump clean and dry." "Keep your newborn at home and do not allow visitors for the first month." "Be sure to keep all scheduled doctor appointments for vaccinations.

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

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 Any time prior to discharge Within 72 hours Within 12 hours

Within one hour

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? skeletal malformations genetic-linked vision hearing

hearing

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? nasal flaring, rate 65 breaths/minute costal breathing pattern crackles on auscultation respiratory rate 45 breaths/minute, irregular

respiratory rate 45 breaths/minute, irregular

Which is the best place to perform a heel stick on a newborn? the fat pads on the lateral aspects of the foot the calcaneus the vascularized flat surface of the foot the front of the heel (the outer arch)

the fat pads on the lateral aspects of the foot

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

Injecting the medication into the vastus lateralis

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. Newborns usually sleep for 16 or more hours each day. Caregivers need to sleep while the baby is sleeping. The infant may sleep through the night around 2 months of age.

Place the infant on the back when sleeping.

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia? Bradycardia Metabolic alkalosis Shivering Hyperglycemia

Bradycardia

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 are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems." "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episode

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

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 should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "It is best practice to change the diaper every 2 to 4 hours, even during the night." "We will apply a moisture barrier cream with every diaper change to prevent diaper rash."

"We will fold down the front of her diaper under the umbilical cord until it falls off."

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? 90 mg/dl (5.00 mmol/L) 70 mg/dl (3.89 mmol/L) 50 mg/dl (2.77 mmol/L) 30 mg/dl (1.67 mmol/L

30 mg/dl (1.67 mmol/L)

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? Inspect for engorgement. Document this as pseudo menstruation. Notify the primary care provider immediately. Obtain a culture of the discharge.

Document this as pseudo menstruation.

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? Place the newborn on its stomach with the head down and gently pat its back. Suction the mouth and then the nose with a suction catheter. Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose.

Dry the newborn and place it skin-to-skin on mother.

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? Place a second stockinette on the baby's head. Place the infant under a radiant warmer. Help the mother provide kangaroo care. Administer a warm bath with temperature slightly higher than usua

Help the mother provide kangaroo care.

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 HBV immunoglobin HiB Hep B

Hep B

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. Lethargy Hyperthermia Jitteriness Bradypnea Seizures

Jitteriness Lethargy Seizures

A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply. -Posture -Arm recoil -Lanugo -Square window -Breast tissue

Lanugo Breast tissue

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Mongolian spot noted on left upper outer thigh. Mottling noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh. Birth trauma noted on left upper outer thigh.

Mongolian spot noted on left upper outer thigh.

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply. Mongolian spots swollen genitals low-set ears enlarged fontanelles short, creased neck

Mongolian spots swollen genitals short, creased neck

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: birth trauma. Mongolian spots. milia. stork bites.

Mongolian spots.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? silver nitrate solution gentamicin ophthalmic ointment erythromycin ophthalmic ointment vitamin K

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be mostappropriate? Notify the primary care provider if the temperature goes lower. Observe the newborn every hour. Assess the newborn's gestational age. Rewarm the newborn gradually.

Rewarm the newborn gradually.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue? It's a mild reaction to the vitamin K injection. The infant needs to be in the sunlight to clear the skin. Yellow is the normal color for some newborns. The tint is due to jaundice.

The tint is due to jaundice.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply. The newborn was febrile at birth but temperature is now normal. There is a family history of hemophilia. The penis is small. The infant is at 33 weeks' gestation. The father is uncircumcised.

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

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply. -Fasten the diaper loosely to prevent unnecessary friction as irritation. -Apply talc powder to the diaper area with each diaper change. -Wash the penis with warm water at each diaper change. -Notify the doctor if the newborn does not void after 4 hours. -Report if there is a bleeding spot the size of a dime on the diaper.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: caput succedaneum. molding. microcephaly. cephalohematoma.

caput succedaneum.

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: erythema toxicum. port wine stain. harlequin sign. nevus flames.

erythema toxicum.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? silver nitrate solution gentamicin ophthalmic ointment erythromycin ophthalmic ointment vitamin K

erythromycin ophthalmic ointment

On an Apgar evaluation, how is reflex irritability tested? tightly flexing the infant's trunk and then releasing it flicking the soles of the feet and observing the response raising the infant's head and letting it fall back dorsiflexing a foot against pressure resistance

flicking the soles of the feet and observing the response

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

harlequin sign.

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? at the fifth intercostal space to the left of the sternum directly adjacent to the sternum at the second intercostals space lateral to the midclavicular line at the fourth intercostal space just superior to the nipple, at the midsternum

lateral to the midclavicular line at the fourth intercostal space

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider? less than 97° F (36.1° C) or greater than 100.5° F (38.1° C) less than 96° F (35.6° C) or greater than 101° F (38.3° C) less than 96.7° F (35.9° C) or greater than 99.5° F (37.4° C) less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. skin rashes jitteriness low-pitched cry lethargy cyanosis

lethargy cyanosis jitteriness

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? Provide hepatitis B vaccination. Administer aquamephyton. Complete the hearing test. Perform the newborn screening.

Administer aquamephyton.

A hepatitis B positive mother delivers a newborn. What precautions would the nurse take in caring for this infant? Select all that apply. The newborn will need to stay in the hospital for several extra days for additional IV medications to treat the infection. Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth. Give the mother a one-time dose of hepatitis B immunoglobulin within 12 hours after delivery. Tell the mother that she cannot breastfeed her newborn due to the infection.

Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth.

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? Assess the baby's temperature. Assess for pain source. Check blood glucose. Place child in a radiant warmer.

Check blood glucose.

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply. If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose. Initiate early feedings for all bottle-fed newborns. Keep the newborns warm in the nursery and covered with a blanket. Offer glucose feedings to all newborns at 1 hour of age. Encourage breastfeeding mothers to nurse immediately after deliv

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

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: Epstein pearls. milia. thrush. vernix caseosa.

Epstein pearls.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Initiate early and frequent breastfeeding. Feed the newborn formula every 4 hours, starting 8 hours after birth. Feed only glucose water for the first 24 hours following birth. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn.

Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn.

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. Assess the newborn for infection. Administer acetaminophen orally. Apply a petrolatum gauze dressing

Monitor the site for bleeding.

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 respiratory rate of 54 breaths/minute abdominal breathing acrocyanosis

nasal flaring

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply. -Keep the newborn with the parent 24 hours per day until discharge. -Place an identification band on both the mother and the newborn immediately after birth, before separating them. -Ask the parents to look at the newborn each time the newborn is brought to the room to be sure that the newborn is theirs. -Obtain the newborn and the mother's thumbprint on the mother's chart. -Have identifying data on the newborn's chart and compare information to that in the mother's chart.

Place an identification band on both the mother and the newborn immediately after birth, before separating them

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. Position the newborn on side with head slightly below body; use a bulb syringe to clear nose. Position the newborn on side, and suction with a bulb syringe.

Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth.

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? Place the newborn on its stomach with the head down and gently pat its back. Suction the mouth and then the nose with a suction catheter. Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose.

Using a bulb syringe, suction the mouth then the nose.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? to enhance the clearing of the newborn's respiratory passages to encourage the development of maternal antibodies to facilitate maternal-infant bonding to aid in maturing the newborn's sucking reflex

to facilitate maternal-infant bonding