chapter 18 exam 2

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 is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term?

3,500 grams Typically, the term newborn weighs 2,500 to 4,000 g.

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

Administer vitamin K. Vitamin K is used to promote blood clotting in the newborn and is priority to administer to the newborn.

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.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply.

It is thinner and more fragile than an adult's Substances are easily absorbed.

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 blanket 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 is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents?

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.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn?

Warmer bed Suction equipment Identification bands 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.

erythema toxicum

also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line.

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 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.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings?

Nasal flaring,Respiratory rate of 64 breaths per minute,Chest retractions Signs of respiratory distress in the newborn include tachypnea (respirations greater than 60 breaths/min), tachycardia (heart rate greater than 160/beats/min), nasal flaring, chest retractions, and generalized cyanosis. Blue hands and feet, referred to as acrocyanosis, is caused by poor peripheral circulation not respiratory distress.

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?

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.

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.

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.

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.

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.

lanugo,breast tissue When assessing physical maturity for a newborn's gestational age assessment, the nurse would assess lanugo and breast tissue. Posture, arm recoil, and square window are components of the neuromuscular maturity assessment.

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse (PMI)?

lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

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 Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the care provider if the newborn has more than two episodes of diarrhea in one day.

A nurse is assessing a newborn's vital signs 2 hours after birth. The newborn had low Apgar scores at birth. Which finding would lead the nurse to notify the health care provider?

pulse rate 100 bpm A pulse rate between 110 and 160 bpm is considered within acceptable parameters

The mother of a newborn asks the nurse, "What are these small red marks on the back of my baby's neck and between the eyes? They seem to more visible when my baby is crying." The nurse would describe this finding as which skin variation?

salmon patches Stork bites or salmon patches are superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip. They are caused by a concentration of immature blood vessels and are most visible when the newborn is crying.

A nurse is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters?

33 cm The average chest circumference is 30 to 36 cm (12 to 14 in). It is generally equal to or about 2 to 3 cm less than the head circumference.

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.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?

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.

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. Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

Bradycardia Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat.