EDAPT: Nursing Care of the Newborn

​For each nursing action, click to specify whether it is anticipated or not needed for Lizzy's care. Select only one answer in each row.

*Anticipated:* Review infant abduction information with parents *Not Needed:* Place the newborn under the radiant warmer Request a gastrointestinal (GI) consult Recommend extending the time between feedings

For each potential order or nursing action, click to specify whether it is anticipated or unrelated/unnecessary to the newborn's care.

*Anticipated:* • Monitor blood glucose levels per protocol • Monitor body temperature per protocol • Reinforce education for Teresa regarding hypothermia prevention • Monitor respiratory rate and status *Unrelated or Unnecessary:* • Supplement with infant formula • Transfer to the newborn nursery • Consult with neonatologist • Assess rectal body temperature

A client is asking whether she should try to feed her newborn when the infant exhibits early feeding cues or wait until the infant is crying. Based on this information, which actions are feeding readiness cues versus non-typical feeding cues? Drag the action to the corresponding column.

*Feeding Readiness Cues:* Makes sucking motion Moving the mouth towards the mom's breast *Non-Typical Feeding Cues​:* Waving the arms in the air​ Hiccupping Stretching the legs out straight

For each reason, indicate if the client is likely to choose formula feeding instead of breastfeeding.

*Formula Feed:* Unsupportive partner Mother of client supports bottle feeding Return to work 6 weeks postpartum Need for early childcare Previous negative breastfeeding experience Social calendar Fear of body exposure *Breastfeed:* Access to a lactation consultant Limited income

​Which interventions would now be indicated, nonessential (or unrelated), or contraindicated for the nurse to provide the newborn at this time?

*Indicated:* Replace wet blankets with dry, warm blankets Auscultate breath sounds Reassess the APGAR score in 5 minutes *Nonessential or Unrelated:* Place the newborn in the bedside warmer Put the newborn skin-to-skin on mother's chest Check the newborn's blood glucose level Administer Narcan *Contraindicated:* Place the newborn in prone position Suction the nares and then the mouth​ Assess respiratory rate for one full minute

Which orders would be indicated, nonessential, or contraindicated? Select the correct column for each order.

*Indicated:* Weigh the newborn daily Observe proper breastfeeding techniques *Nonessential:* Discuss Louise's career goals *Contraindicated:* Discourage bottle/formula feedings

The nurse should __________. Then the nurse should collect additional information regarding the __________.

Review maternal history regarding hearing loss to plan for Lizzy's hearing test. Policy for ID bracelet replacement since the newborn's bracelet fell off of the leg.

The nurse is caring for a newborn one minute after delivery. Which is the best indication that the newborn is adjusting well to extrauterine life?

Strong, vigorous cry​

Which nursing action is most critical when caring for the newborn immediately following birth?

Suction the mouth and nares

The nurse is assessing a newborn's vital signs. Which findings require follow-up? Select all that apply.

Axillary temperature 97.5°F (36.4°C) Respiratory rate 20 breaths per minute Apical heart rate 100 beats per minute

A nurse is caring for a mother who is deciding whether to breast or bottle feed her newborn. The client asks, "If formula is safe to feed the newborn, why is breast milk better?" Which is the best response by the nurse?

"Breast milk contains important immunoglobulins."

Why is vitamin K administered to newborns? Select all that apply.

The newborn intestinal tract is sterile and does not contain bacteria that produces vitamin K​. To prevent vitamin K deficiency bleeding (VKDB)​.

Based on these findings, which conclusions does the nurse achieve? Select all that apply.

1-minute APGAR score of 6 Additional cardiopulmonary support is needed

The nurse is caring for a mother and her newborn. The nurse observes the newborn in the crib. Which findings indicate the mother understands the principles of safe sleep?

The newborn is in supine position wrapped in two blankets with a cap on the head.

Madison asks the nurse why she must prepare a new bottle for each feeding when there is always leftover formula from the previous feeding. She states, "It just seems so wasteful." What is the best response by the nurse?

"Bacteria can grow rapidly in warm milk that is left sitting out and unused."

What APGAR score does the nurse document?

*0:* Muscle tone is absent or there is a lack of flexion *1:* Pulse is below 100 bpm Grimacing Respiration is slow and irregular *2:* Body is completely pink

Drag each common newborn skin assessment finding to its description. ​

*Milia* - Small white spots on the nose and chin similar to acne. *Rash* - Non-contagious normal response to exposure to allergens during the adjustment to extrauterine life. *Lanugo* - Fine hairs that appear on the bodies of newborns of lower gestational age. *Mongolian spots* - Increased pigmentation common in darker-skinned people. *Vernix* - Skin protectant that covers the body of infants of lower gestational age; dissolves away as the fetus nears term *Strawberry birthmarks and stork bites* - Reddened areas that become more prominent with crying. *Jaundice* - After 48 hours of life, yellowing skin caused by bile pigment deposits in the skin. *Acrocyanosis* - Blue hands and feet lasting 7-10 days as circulation improves​.

For each newborn assessment finding, indicate whether it is normal or requires follow-up.

*Normal:* Fontanelles are firm and flat Molding Caput Apical Pulse rate158 beats/min Eyelids are edematous Prominent abdomen Brief periods of apnea Up to 7% drop in birth weight in first 24-48 hours *Requires Follow-Up:* Head is disproportionately small for the body Eyes produce cleardrainage when fussy Prominent chest Respiratory rate 20 breaths/min Axillary temperature 99.9°F Tufts of hair at base of spine Arms relaxed along sides of body Murmur

The nurse is assessing the newborn and observes all of the following findings. Indicate which findings require follow-up and which do not.

*Requires Follow-Up:* • Axillary temperature 97.4°F • Apical pulse rate 170 beats/minute at rest • Birthweight 5 lbs. 0 oz., 36 weeks SGA (small for gestational age) • Newborn is in his crib wearing a onesie and wrapped in one blanket *Does Not Require Follow-Up:* • Eyelids edematous • Arms and legs remain flexed against the body • Respiratory rate 40 breaths/minute with brief periods of apnea • Vernix found in creases of armpits • Regurgitating mucous after feeding • Teresa uses skin-to-skin contact when breastfeeding

​Select the clinical findings that require nursing action and those that do not require nursing action.

*Requires Nursing Action​:* Wearing a wet diaper Maternal history of hearing loss Newborn ID bracelet in crib *Does Not Require Nursing Action​:* Newborn is blood type A+ Breastfeeding every 2-3 hours Temperature 98.6ºF (37ºC) Black, tarry stools

The respiratory rate is ______ breaths per minute. The apical heart rate is ______ beats per minute. The axillary temperature is ______ °F.

50 150 99.3

Which APGAR score reflects the nurse's assessment?

6

Which facts about newborn safety and activity should the nurse know and understand? Select all that apply.

A high-pitched cry should be evaluated by the healthcare provider. The identification bracelets should be matched to the mother's every time the newborn is brought back to the mother.

What potential issues may the newborn be at risk for? Select all that apply.

Abduction Hearing loss

A newborn has blue fingertips and toes. This finding is consistent with __________.

Acrocyanosis

In the first minute following delivery, the nurse's findings include the following, some or all of which may be abnormal. Which findings require immediate follow-up by the nurse? Select all that apply.

Apical heart rate 90 beats per minute Weak cry Minimal response to suctioning

The nurse is assessing Teresa and her newborn and observes the following. Identify which findings correlate to the newborn's axillary temperature reading of 97.4°F.

Birthweight 5 lbs. 0 oz., 36 weeks SGA (small for gestational age) Infant received a bath 20 minutes ago Newborn is in his crib wearing a onesie and wrapped in one blanket

A 17-year-old primiparous woman delivered a healthy newborn. The mother is worried about bathing her newborn at home. In planning for their discharge, which approach is best in addressing the new mother's concern?

Demonstrate infant bath and provide time for the mother to practice.

How can the nurse help prevent newborn abduction in the hospital? ​Select all that apply.

Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery​. Ensure the newborn's identification bracelet is securely in place. Ensure the newborn's tracking bracelet is securely in place.

Which statement reflects the newborn's visual abilities at birth?

From birth, newborns can best see objects held 8-10 inches away.

The newborn's umbilical cord at delivery normally contains which components? Select all that apply.

Gelatinous protective tissue One vein and two arteries

The nurse observes pink stains in the diaper of a 1-day-old, male newborn. What conclusion does the nurse make based on this finding?

He has uric acid crystals in his urine.

The nurse is providing education regarding prevention of hypothermia to Teresa. The nurse comes back later and finds that the newborn's axillary body temperature is 98.0ºF (36.6°C). Which additional findings indicate to the nurse that the newborn's hypothermia has been resolved?

He is alert and sucking his hand.

The nurse is teaching a client about proper techniques for bottle feeding. Which action by the client indicates an understanding of the instructions?

Keeps the nipple full of formula while feeding.

Review the client's electronic health record (EHR), which assessment findings require immediate follow-up? Select the correct answers from the Nurses' Notes tab below.

Needs to eat every 6 hours Get used to sleeping through the night Keep the baby warm and snuggled tight when preparing to breastfeed Leftover formula Most formula is the same Mix them together Really won't have poopy diapers Hope my partner will help me He doesn't really want me to breastfeed

The labor nurse is caring for Tiffany in the second stage of labor. The fetal heart rate pattern has shown a baseline of 120-130 beats per minute with recurrent variable decelerations ranging from 80-90 beats per minute and lasting 15-40 seconds. Based on these findings, what might the nurse anticipate when the fetus is delivered? Select all that apply.

Nuchal cord Low APGAR scores

What is the cause of molding in the newborn skull?

Overlapping of the unfused bones compressed during vaginal delivery.

Which instructions should the nurse provide to both formula and breastfeeding mothers?

Various ways to stimulate a sleepy baby who is reluctant to feed.

Which two of the listed healthcare provider orders or actions should be addressed first?

Vital signs Newborn hearing test

What APGAR score does the nurse document?

*0:* Respiration is absent Reflexes are flaccid *1:* Body is pink with blue extremities ​​Arms and legs are flexed *2:* Pulse is over 100 bpm

Based on the assessment findings, have conditions improved, not changed, or declined?

*Improved:* Feeding schedule increased to every 3 hours Decision to breastfeed and meet with lactation consultant Changed diaper with urine and stool *No change:* Maternal vitals *Declined:* Newborn vitals

Which findings indicate that Molly understands the plan for newborn care while in the hospital? Select all that apply.

Molly makes eye contact with Lizzy and supports her head when cradling her. Molly changes Lizzy's wet and stool-filled diapers. Molly verifies the identification bracelet number with the nurse as Lizzy is brought into the room. Molly notifies the nurse if the identification (ID) bracelets are loose or fall off.

The nurse is reviewing a formula-fed newborn's schedule. The client is taught to wake the infant, who is 36-hours-old, every 3 hours during the day and at least every 4 hours at night. How would the nurse describe the feeding routine?

Necessary during the first 24 to 48 hours after birth.

A newborn born one hour ago is wrapped in blankets and sleeping in the crib at the mother's bedside. The axillary temperature is 97.6ºF (36.4ºC). Which actions should the nurse initiate?

Place newborn skin-to-skin on mother's chest.

​The nurse discusses the plan of care with Tiffany's obstetrician. Which potential actions does the nurse anticipate will be appropriate for the newborn's care at this time?

Place the newborn skin-to-skin on Tiffany's chest Obtain temperature

​Which 2 priorities should the nurse address first?

Provide supplemental oxygen Continue to gently pat and vigorously rub the newborn's back

A nurse completes an assessment 1 hour after a circumcision was performed. The nurse would anticipate the area to be __________.

Reddened

What screening/testing should newborns have after they have been on formula for 36-48 hours?

Screening for phenylketonuria (PKU)

The nurse observes several interactions between a postpartum woman and her new daughter. What behavior would the nurse identify as appropriate behavior regarding parent-infant attachment? Select all that apply.

Talks and coos to her daughter Cuddles her daughter close to her Tells visitors how well her daughter is feeding

When preparing formula from powder, the client should mix with __________ water and warm the formula __________. Prepared but unused formula may be stored in the refrigerator for __________ hours.

Tap By running under warm tap water 48

The nurse should first confirm __________. Then she should discuss the adjustments that need to be made regarding __________.

The last feeding time and amount The frequency of newborn feeding

A 12-hour-old newborn is found to have a dark brown, sticky, thick mass of stool in his diaper. With what is this finding consistent?

The newborn digested amniotic fluid in utero.

A nursing instructor asks a student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. Which statements by the student demonstrate their understanding of administering erythromycin? Select all that apply.

"I will ensure that consent is in the client's record prior to administration." "I will cleanse the neonate's eyes before instilling the ointment." "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur." ​​"I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth."

The nurse is providing discharge instructions to a client who plans to bottle feed her newborn. Which statement by the client indicates a need for further teaching?

"My baby needs to take the entire bottle at each feeding to maintain weight gain."

The newborn is dressed in additional clothing, a cap is placed on his head, and he is wrapped in warm blankets. An hour later, his axillary temperature is 97.0ºF. His respiratory rate is 36 breaths/minute. The nurse notifies the healthcare provider and receives orders. Which two actions should the nurse take next?

Assess the newborn's blood glucose level Place the newborn in a radiant warmer

How can the nurse help prevent newborn abduction in the hospital? Select all that apply.

Continually ensure that the newborn's identification bracelet is securely in place. Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery. Continually ensure that the newborn's tracking bracelet is securely in place.

What is the role of the nurse when caring for Louise and Victoria?

Educate the bottle-feeding mother to hold the newborn in a semi-upright position to prevent aspiration. Ensure that the breastfeeding newborn is latched correctly and is unlatched correctly. Educate the mother to burp the newborn to prevent regurgitation. Ensure that the newborn is receiving adequate nutritional intake in a safe manner.

Which nursing actions promote initial bonding immediately following birth? Select all that apply.

Encourage breastfeeding within the first hour Delay full assessment for 1 hour Place infant on mother's chest Involve partner in care

A woman delivers a newborn vaginally. What can the postpartum nurse do to encourage mother-newborn bonding? ​Select all that apply.

Encourage the mother to hold the newborn from birth. Encourage breastfeeding within the first hours of birth. Assess for signs that indicate normal attachment is taking place. Postpone nursing actions that require the newborn to be removed from the mother's arms.

Which statement best represents recommendations from the American Academy of Pediatrics about infant nutrition?

Exclusive breastfeeding for the first 6 months of life.

For what potential issues may Louise and Victoria be at risk? Select all that apply.

Inadequate weight gain Early cessation of breastfeeding Risk of developing allergies Failure to thrive Anxiety

The nurse observes a new mother placing her newborn on the bed between her legs, then unwrapping the newborn to change the diaper and clothes. She stops to answer her phone and is observed leaving the newborn unwrapped. What implications may this have? Select all that apply.

Increased oxygen demand and consumption in the newborn Hypothermia in the newborn Newborn's blood glucose level may decrease

The nurse obtains an axillary body temperature of 97ᵒF (36.1ᵒC) on a newborn. Based on this finding, what assessment cues should alert the nurse? Select all that apply.

Lethargy Hypoglycemia Tachypnea Decreased blood oxygen saturation

What is the concern with Teresa's newborn being hypothermic? Select all that apply.

May indicate physical immaturity Can lead to hypoglycemia May indicate inadequate thermoregulation abilities

The nurse weighs a newborn who is 40 weeks gestation and obtains a measurement of 8 pounds, 11 ounces. Which reflects how the nurse will describe this measurement?

Within normal range for a term neonate.