Chapter 18: Nursing Management of the Newboron

Arrange the following reflexes in the correct order of their disappearance into adulthood 1) stepping 2) babinski sign 3) grasp 4) rooting 5) gag reflex

1, 3, 4, 2, 5

head circumference

33-37 cm

Length

45-55 cm

12) A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? SATA a. Lethargy b. Low-pitched cry c. Cyanosis d. Skin rashes e. Jitteriness

A, C, E Rationale: The nurse should monitor the newborn for lethargy, cyanosis, and jitteriness. Low pitched crying or rashes on the infants skin are not signs generally associated with hypoglycemia

The ____________ fontanel of the baby is diamond shaped and closes by age 18 to 24 months

Anterior

Weight

2500- 4000 g

What is erythema toxicum?

A benign idiopathic transient rash occurring in as many as 70% of all newborns.

1) the nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a. within 30 minutes after birth, in the birthing area b. within the first 2-4 hours, when the newborn reaches the nursery c. prior to the newborn being discharged d. 24 hours after the newborn's birth

B Rationale: The nurse should complete the second assessment for the newborn within the first 2-4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged.

_____________ are unopened sebaceous glands frequently found on a newborn's nose

Milia

How can a nurse test Moro reflex?

To elicit this reflex, the newborn is placed on its back. The upper body weight of the supine newborn is supported by the arms with use of a lifting motion, without lifting the newborn off the surface. The newborn initially appears startled and then relaxes.

11) A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? SATA a. Provide warm water to drink b. Provide oxygen supplementation c. Massage the newborn's back d. Ensure the newborn's warmth e. Observe respiratory status frequently

b, d, e Rationale: The nurse should given the newborn oxygen, ensure the newborns warmth, and observe the newborns respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the back

What is caput succedaneum?

diffuse edema that crosses fetal scalp suture lines that will disappear in 1-3 days

Vitamin K, a fat soluble vitamin, promotes blood clotting by increasing the synthesis of ________________ by the liver

prothrombin

What is colostrum?

"early breast milk" contains protein, fat, secretory IgA, and minerals. W/in one wk postpartum, mature milk w/ protein, fat, lactose, and water is produced

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

A Rationale: 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 as described in B, and blue or purple splotches on buttocks (Mongolian Spots) 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.

The _____________ score is used to evaluate newborns at 1 minutes and 5 minutes after birht

APGAR

________________ sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of paleness on one side of the body and ruddiness on the other.

Harlequin

3) The nurse is educating a client who is breastfeeding her 2 week old newborn regarding the nutritional requirements of newborns, according the to AAP. Which response by the mother would validate her understanding of the information she received? a. I will feed him at least 30 cc of water daily b. I need to give him iron supplements daily c. I will give him vitamin D supplements daily for the first 2 months of life d. Since we live in a rural area, I must ensure he receives adequate fluoride supplementation

C Rationale: As per the APP, all newborns should receive a daily supplement of Vit D during the first 2 months of life to prevent rickets and Vit D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water.

9) 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 is adjusting well to extrauterine life c. The infant is experiencing moderate difficulty in adjusting extrauterine life d. The infant probably has either a congenital heart defect or an immature respiratory system

C Rationale: 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 sever distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0-3 points represents sever distress in adjusting to extrauterine life.

8) 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? a. Tape electronic thermistor probe to the abdominal skin b. Obtain the temperature orally c. Place electronic temperature probe in the midaxillary area d. Obtain the temperature rectally

C Rationale: The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

7) A nurse, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? a. Bruising from the birth process b. An immature autoregulation of blood flow c. An allergic reaction to the soap used for the first bath d. Concentration of immature blood vessels

D Rationale: A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

Chest circumference

32-38 cm

5) A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? a. hold the newborn upright with the newborn's head on the mother's shoulder b. lay the newborn on its back on its mothers lap c. gently rub the newborn's abdomen while the newborn is in a sitting position. d. lay the newborn on its abdomen in the mother's lap and gently pat the buttocks.

A Rationale: The nurse should instruct the mother to hold the newborn upright with the newborns head on her mothers shoulder. Alternatively the nurse can also suggest the mother sit with the newborn on her lap with the newborn lying face down.

4) A first time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? a. use the sealed and chilled milk within 24 hours b. use any frozen milk within 6 months of obtaining it c. use microwave ovens to warm the chilled milk d. refreeze any unused milk for later use if it has not been out more than 2 hours

A Rationale: The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwaves, or to refreeze. Instead, the nurse should instruct the woman to use frozen milk within 3 months, to avoid microwaves, and to not refreeze.

How can a mother achieve the football hold position for breastfeeding

By holding the infants back and shoulders in the palm of the mothers hand and tucking the infants body under the mothers arm. The mothers hand should support the breast in a C position and bring it to the infants lips to latch on until the infant begins to nurse

10) 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. Expose the newborn's bottom to air several times a day b. Use only baby wipes to cleanse the perianal area c. Use products such as talcum powder with each diaper change d. Place the newborn's buttocks in water water after each void or stool

A Rationale: The nurse should instruct the parent to expose the newborns 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 newborns buttocks in warm water after having had a diaper on all night but not with every diaper change.

13) A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? SATA a. Take warm to hot showers to encourage milk release b. Feed the newborn in the sitting position only c. Express some milk manually before breastfeeding d. Massage the breasts from the nipple toward the axillary area e. Apply warm compresses to the breasts prior to nursing

A, C, E Rationale: To relieve breast engorgement in the client, the nurse should educate the client to take warm to hot showers to encourage milk release, express some milk manually before breast feeding and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions -- sitting up and then lying down. The breasts should be massaged from under the axillary area, down toward the nipple.

__________________ is a localized effusion of blood beneath the periosteum of the skull of the newborn

Cephalhematoma

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

B Rationale: 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. The newborn does normally produce several stools per day, but should wet 6-10 diapers rather than 3-4 per day. The newborn should consume approximately 2oz of formula per pound of body weight per day not per feeding

What is the use of fiber optic pads in treatment of physiologic jaundice?

Fiber optic pads are used for treatment of physiologic jaundice and can be wrapped around newborns or newborns can lie upon them. These pads consist of a light this is delivered from a tungsten halogen bulb through a fiver optic cable and is emitted from the sides and ends. They work on the premise that photo-therapy can be improved by delivering higher intensity therapeutic light to decrease bilirubin levels.

_____________ refers to the soft, downy hair on the newborn's body

Lanugo

Babies weighing more than the 90th percentile on standard growth charts are referred to as ___________________ for gestational age

Large

____________ babies are babies with placental aging who are born after 42 weeks

Postmature

14) A nurse is performing a detailed newborn assessment of a female newborn. Which observations indicate a normal finding? SATA a. Mongolian spots b. Enlarged fontanelles c. Swollen genitals d. Low set ears e. Short, creased neck

a, c, e Rationale: Mongolian spots, swollen genitals, and a short creased neck are normal findings in a newborn female. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks on the newborn. Female babies may have swollen genitals as a result of maternal estrogen. The newborns neck will appear almost nonexistent because it is so short. Creases are usually noted. Enlarged fontanelles are associated with hydrocephaly; congenital hypothyroidism; trisomies 13, 18, and 21; and various bone disorders such as osteogenesis imperfecta. Low set ears are characteristic of many syndromes and genetic abnormalities such as trimosies 13 and 18, and internal organ abnormalities involving the renal system.

Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness is called ______________

acrocyanosis