Chapter 18: Nursing Management of the Newborn

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? A. Caregivers need to sleep while the baby is sleeping. B. Place the infant on the back when sleeping. C. The infant may sleep through the night around 2 months of age. D. Newborns usually sleep for 16 or more hours each day.

B. Place the infant on the back when sleeping. Explanation: 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. Pg. 612 or PPT 18 Slide 22

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse? A. "Keep your newborn at home and do not allow visitors for the first month." B. "Be sure to keep all scheduled doctor appointments for vaccinations." C. "Always wash your hands before you pick up or provide care to your newborn." D. "Be sure to keep the newborn's umbilical cord stump clean and dry."

C. "Always wash your hands before you pick up or provide care to your newborn." Explanation: Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy. Pg. 613

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

A. Check blood glucose. Explanation: 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. Pg. 619

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? A. It is a normal skin finding in a newborn. B. It is a self-limiting virus that does not require treatment. C. It is an indication that the woman has mistreated her newborn. D. It is a sign of a group B streptococcus (GBS) skin infection.

A. It is a normal skin finding in a newborn. Explanation: This rash is most likely is erythema toxicum, also known as newborn rash. Pg. 596 or PPT 18 Slide 15

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. Warmer bed B. Ophthalmoscope C. Suction equipment D. Glucose water E. Identification bands

A. Warmer bed C. Suction equipment E. Identification bands Explanation: 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. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn. Pg. 591

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. A. Provide warm water to drink. B .Observe respiratory status frequently. C. Ensure the newborn's warmth. D. Provide oxygen supplementation. E. Massage the newborn's back.

B .Observe respiratory status frequently. C. Ensure the newborn's warmth. D. Provide oxygen supplementation. Explanation: 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. Pg. 617

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? A. Just before discharge home B. 36 hours before the infant is discharged home with its parents C. 24 hours after the newborn's first protein feeding D. When the infant is 48 hours old

C. 24 hours after the newborn's first protein feeding Explanation: 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. Pg. 592

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? A. The infant requires immediate and aggressive interventions for survival. B. The infant probably has either a congenital heart defect or an immature respiratory system. C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. D. The infant is adjusting well to extrauterine life.

C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. Explanation: 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. Pg. 583 or PPT 18 Slide 5

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? A. Place the newborn's buttocks in warm water after each void or stool. B. Use only baby wipes to cleanse the perianal area. C. Use products such as talcum powder with each diaper change. D. Expose the newborn's bottom to air several times a day.

D. Expose the newborn's bottom to air several times a day. Explanation: The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change. Pg. 609 or PPT 18 Slide 21

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? A. lack of subcutaneous fat B. continual crying C. constriction of blood vessels D. continual kicking

A. lack of subcutaneous fat Explanation: Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying. Pg. 567 or PPT 17 Slide 10

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? A. Determine which hospital unit the woman works on. B. Ask if the client actually sent the woman. C. Inform the woman she cannot transport the baby. D. Look at the woman's hospital identification badge.

D. Look at the woman's hospital identification badge. Explanation: 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. Pg. 587-588

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as: A. potential for respiratory distress. B. cold stress. C. poor oxygenation. D. acrocyanosis.

D. acrocyanosis. Explanation: Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress. Pg. 594

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? A. Feeding the infant more formula whenever she begins to fuss B. Swaddling the infant before returning to the crib C. Rocking and talking to the infant D. Gently patting or stroking the infant's back

A. Feeding the infant more formula whenever she begins to fuss Explanation: 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. Pg. 628

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? A. Since it looks like a milk curd, no action is needed. B. Rinse the tongue off with sterile water and a cotton swab. C. Report the finding to the pediatrician. D. Wipe the tongue off vigorously to remove the white patches.

C. Report the finding to the pediatrician. Explanation: 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. Pg. 599

The Apgar score is based on which 5 parameters? A. heart rate, breaths per minute, irritability, tone, and color B. heart rate, breaths per minute, irritability, reflexes, and color C. heart rate, muscle tone, reflex irritability, respiratory effort, and color D. heart rate, respiratory effort, temperature, tone, and color

C. heart rate, muscle tone, reflex irritability, respiratory effort, and color Explanation: 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. Pg. 583 or PPT 18 Slide 4

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation? A. Sleeping for short intervals B. Apnea episodes C. Gastroesophageal reflux D. Sudden infant death syndrome

D. Sudden infant death syndrome Explanation: The 'back to sleep' campaign is a national campaign used to educate the public concerning the fact that the proper position for sleep of infants is on their backs to help decrease the risk of SIDS. Placing the infant on his or her back to sleep does not reduce the risk for gastroesophageal reflux, apnea episodes, or sleeping for short intervals. Pg. 612 or PPT 18 Slide 22

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? A. Anesthetic may not be effective during the procedure B. Fewer complications than if done later in life C. Reduced risk of penile cancer D. Lower rate of urinary tract infections

A. Anesthetic may not be effective during the procedure Explanation: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure. Pg. 611

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? A. Ask to see the woman' hospital identification badge. B. Ask the woman to bring the infant back when the doctor finishes the examination. C. Call the nursery to confirm the doctor does indeed need this infant at this time. D. Ask how long the infant will be gone since her next feeding is in 30 minutes.

A. Ask to see the woman' hospital identification badge. Explanation: 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. Pg. 587

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? A. Check the identification badge of any health care worker before releasing baby from room. B. Check the name on the baby's identification bracelet. C. Provide a list of approved visitors who came spend time with the infant. D. Send a family member to accompany the infant when leaving the room.

A. Check the identification badge of any health care worker before releasing baby from room. Explanation: 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. Pg. 587

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? A. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. B. Mottling noted on left upper outer thigh. C. Harlequin sign noted on left upper outer thigh. D. Birth trauma noted on left upper outer thigh.

A. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Explanation: A congenital dermal melanocytosis (slate gray nevi, previously known as 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. Pg. 595 or PPT 18 Slide 15

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? A. Suggest the parent stop the feeding because the newborn is full. B. Encourage the parent to burp the newborn to get rid of air. C. Instruct the parent to stop feeding for a few minutes and then restart. D. Urge the parent to prop the bottle for the rest of the feeding.

B. Encourage the parent to burp the newborn to get rid of air. Explanation: Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed. Pg. 615 or PPT 18 Slide 23

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? A. Perform a 3-minute surgical-type scrub. B. Wear clean gloves. C. Use infection transmission precautions. D. Clean hands with a betadine scrub.

B. Wear clean gloves. Explanation: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client. Pg. 608

A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor? A. lanugo B. congenital dermal melanocytosis (slate gray nevi) C. vascular nevi D. bruising

B. congenital dermal melanocytosis (slate gray nevi) Explanation: The mark described is congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots), which occurs in ethnicities with darker colored skin. This is a normal finding that should disappear within one to tow years. It does require documentation. Lanugo is the fine hair on the newborn's body when it is born. Vascular nevi are birthmarks. Although the slate gray nevi may look like bruising, they are not. Pg. 595 or PPT 18 Slide 15

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. "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." B. "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." C. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." D. "Your newborn should finish a bottle in less than 15 minutes."

C. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." Explanation: 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. Pg. 621

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? A. "I will change my baby's diapers frequently." B. "I will give sponge baths until the umbilical cord falls off." C. "I can use talc powders to prevent diaper rash." D. "It is not necessary to give my baby a bath daily."

C. "I can use talc powders to prevent diaper rash." Explanation: Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct. Pg. 607

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: A. milia. B. oral candidiasis (thrush). C. Epstein pearls. D. vernix caseosa.

C. Epstein pearls. Explanation: Epstein pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Oral candidiasis (thrush) is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. Pg. 604

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? A. If the fontanel (fontanelle) feels full, then this is normal. B. This is an abnormal finding and needs to be reported immediately. C. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). D. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle).

C. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). Explanation: 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 (fontanelle). The fontanel (fontanelle) should not be bulging under any circumstance in a newborn. Pg. 596

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply. A. Have identifying data on the newborn's chart and compare information to that in the mother's chart. B. Obtain the newborn and the mother's thumbprint on the mother's chart. C. Place an identification band on both the mother and the newborn immediately after birth, before separating them. D. 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. E. Keep the newborn with the parent 24 hours per day until discharge.

C. Place an identification band on both the mother and the newborn immediately after birth, before separating them. Explanation: When a newborn is born, three to four identical bracelets are prepared and placed on both the mother and the infant with pertinent data such as mother's name, hospital number, date of birth, time of birth, the newborn's gender along with the health care provider for the mother. Thumbprints are not a reliable way to identify a newborn and mother. Nurses compare information on the bands, not in the chart. The nurse would never ask the parents to identify their newborn by appearance since newborns look a lot alike. Lastly, it may be hard to keep the newborn with the parents all the time due to health care provider visits and procedures such as circumcisions. Pg. 587

The nurse is conducting a prenatal class explaining the various activities that will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? A. Protect tear ducts from vaginal bacteria B. Prevent infection of the umbilical cord C. Prevent infection of the eyes from vaginal bacteria D. Protect the urethra from fecal material

C. Prevent infection of the eyes from vaginal bacteria Explanation: Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra. Pg. 589 or PPT 18 Slide 12

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? A. Apgar score B. heart rate C. blood sugar D. temperature

C. blood sugar Explanation: Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl). Pg. 619 or PPT 18 Slide 18

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? A. small pink or red patches on the newborn's eyelids and back of the neck B. fine red rash noted over the chest and back C. bright red, raised bumpy area noted above the right eye D. blue or purplish splotches on buttocks

C. bright red, raised bumpy area noted above the right eye Explanation: A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (congenital dermal melanocytosis (slate gray nevi) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear within a few days. Pg. 596

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

D. "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." Explanation: 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, prevent ophthalmia neonatorum, or strengthen the immune system. Pg. 588 or PPT 18 Slide 12

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? A. "We'll swaddle him snuggly to make him feel secure." B. "We'll turn on the mobile that's hanging above his head in his crib." C. "We'll lightly rub his back as we talk to him softly." D. "We'll hold off on feeding him for a while because he might be too full."

D. "We'll hold off on feeding him for a while because he might be too full." Explanation: 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. Pg. 615

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? A. Administer an oral dose of vitamin K to the newborn. B. Assume that the parents refused this medication for their infant. C. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn. D. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

D. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Explanation: 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. Pg. 588

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

D. Using a bulb syringe, suction the mouth then the nose. Explanation: 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. Pg. 587

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: A. stork bites. B. erythema toxic. C. congenital dermal melanocytosis (slate gray nevi). D. harlequin sign.

D. harlequin sign. Explanation: 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. Congenital dermal melanocytosis (slate gray nevi, previously known as 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. Pg. 596 or PPT 18 Slide 15