MATERNAL CHAPTER 18 (PREP U)
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect?
The infant remains free of bleeding
How long is the neonatal period for a newborn?
28 days
A nurse is providing care to a newborn. Which intervention would be most appropriate to help prevent heat loss? Select all that apply A. swaddling B. skin-to-skin contact C. gentle drying of the skin D. placing cap on the head
A. swaddling B. skin-to-skin contact C. gentle drying of the skin D. placing cap on the head
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?
Anesthetic may not be effective during the procedure
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation
B) Conduction
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 sign of a group beta streptococcus skin infection. B) It is a normal skin finding in a newborn. C) It is a self-limiting virus that does not require treatment. D) It is an indication that the woman has mistreated her newborn.
B) It is a normal skin finding in a newborn.
The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?
Blood sugar 42 mg/dL
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation
C) Convection
The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? A. Vitamin K B. HiB C. Hep B D. HBV immunoglobin
C. Hep B
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? A. Using a 21-gauge needle B. Injecting 1cc of medication C. Injecting the medication into the vastus lateralis D. Injecting at a 45-degree angle
C. Injecting the medication into the vastus lateralis
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.
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?
Conduction
The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?
Cooperation by the parents with the hospital policies
A nurse is conducting the initial assessment for a 3-hour-old newborn and notes the following: RR 30 bpm, BP 60/40 mm Hg, HR 155 bpm, axillary temperature 98.2°F (36.8°C), and the newborn is in a state of quiet alert. What action should the nurse prioritize?
Document the data.
The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action?
Infant C - 48 mg/dL
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch.
Which statement is false regarding bathing the newborn?
To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
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
A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client?
Wrap the infant in a blanket and hand to the mother for bonding.
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
blood sugar
A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?
The breakdown of RBCs release bilirubin, which the liver cannot excrete.
A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What signs of distress would validate the nurse's concerns?
Temperature instability
The nurse has administered an opthalmic agent for eye prophylaxis, as prescribed. What outcome indicates that this intervention has been effective?
The infant remains free of opthalmia neonatorum
Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:
milia.
All the options are signs of respiratory distress in the newborn except:
respiratory rate >50 breaths/minute.
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?
"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
The student nurse is attending their first cesarean delivery and is asked by the mentor what should be carefully assess in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response
"There is more fluid is present in the lungs at birth after a cesarean delivery than after a vaginal delivery."
A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?
"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm."
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?
Using a bulb syringe, suction the mouth then the nose.
It is common for a newborn to have one or two erupted teeth (natal teeth) at birth
False
The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best?
Inform the practitioner and cancel the procedure.
A newborn infant at 36 hours of age is jaundiced. The mother is breast-feeding. What intervention is appropriate to increase the excretion of bilirubin?
Instruct the mom to feed every two to three hours.
The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?
It keeps alveoli from collapsing with breaths.
The nurse is assisting with the admission of a newborn boy to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of htis dark-skinned infant. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?
Moro
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?
Perform a heel stick to obtain a blood sample for testing for glucose level.
A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action?
Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.
When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Use talc powders to prevent diaper rash." b) "Change diapers frequently." c) "Give the newborn sponge baths until the umbilical cord falls off." d) "Daily tub baths are not necessary."
a) "Use talc powders to prevent diaper rash."
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: a. have a smaller body surface compared to body mass. b. lose more body heat when they sweat than adults. c. have an abundant amount of subcutaneous fat all over. d. are unable to shiver effectively to increase heat production.
d. are unable to shiver effectively to increase heat production.
When assessing the newborn's umbilical cord, what should the nurse expect to find? a) Two smaller arteries and one larger vein b) One smaller artery and two larger veins c) Two smaller veins and one larger artery d) One smaller vein and two larger arteries
two smaller arteries and one larger vein
The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? A) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth B) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth C) Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth D) Two doses of the hepatitis B immunoglobulin within 24 hours of birth
A) Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus.
Under which circumstances should gloves be worn in the newborn nursery? Select all that apply
Providing the first bath Changing a diaper Performing a heel stick Accucheck
A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description
Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents?
Holding and comforting the newborn will not cause the infant to become spoiled
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? A. Evaporative B. Conductive C. Convective D. Radiating
A. Evaporative
The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply. A. Give Hepatitis B immune globulin. B. Obtain consent from the mother. C. Administer Hepatitis B vaccination. D. Bathe the newborn thoroughly.
A. Give Hepatitis B immune globulin. B. Obtain consent from the mother. C. Administer Hepatitis B vaccination. D. Bathe the newborn thoroughly.
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? A. Instill 0.5% ophthalmic erythromycin. B. Instill 0.5% ophthalmic tetracycline. C, Instill 0.5% ophthalmic silver nitrate. D. Watch for signs of eye irritation.
A. Instill 0.5% ophthalmic erythromycin.
