Chapter 18- nursing management of the newborn PrepU
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:
7-10
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding?
2 arteries and 1 vein
A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?
Administer vitamin K
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?
Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh.
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.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?
Identify the newborn
A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug:
Intramuscularly
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?
Prevent infection of the eyes from vaginal bacteria
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn?
Toes fan out when the sole of the foot is stroked
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.
temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
Breastfeed the infant every 2 to 4 hours on demand.
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.
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.
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
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?
"The opening of his urethra in located on the under surface of the tip of the penis."
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?
108 bpm
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
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?
It is a normal skin findings on a newborn.
When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex?
Moro
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.
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. Determine the mother's room temperature during the visit.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn?
Toes fan out when sole of foot is stroked.
A nurse is preparing to administer eye prophylaxis to a newborn. Which agent would the nurse most likely use?
erythromycin
On an Apgar evaluation, how is reflex irritability tested?
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:
harlequin sign.
A woman has just given birth vaginally to a newborn. Which action will the nurse do first?
suction the mouth and nose
The Ballard scoring system evaluates newborns on which two factors?
physical maturity and neuromuscular maturity
Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?
weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm
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?
Expose the newborn's bottom to air several times a day.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as do the infant's forehead and nose. What would the nurse do next?
Obtain a transcutaneous bilirubin