Maternity Newborn

The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student? 1. Inject at a 45-degree angle. 2. Use a 22-gauge, 1-inch needle for the injection. 3. Inject into skin that has been cleansed with alcohol. 4. Do not massage the injection site after administration

3 Rationale: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ½-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute; this removes organisms and prevents infection. It is administered at a 90-degree angle. The site is massaged after removing the needle to increase absorption of the medication.

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma? 1. Checking the urine for blood 2. Monitoring urinary output patterns 3. Observing for contractures of the extremities 4. Testing for equality of extremities when stimulating reflexes

4 Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if actively bleeding, this can cause changes in the stimuli responses in the extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant, after delivery, normally is incontinent of urine. Blood in the urine would indicate abdominal trauma. Option 3 is incorrect because contractures do not occur this soon after delivery. *Checking newborn reflexes is a basic assessment for determining neurological complications in this age group.*

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly? 1. The mother begins to wash the newborn by starting with the eyes and face. 2. The mother cleans the newborn's ears and then moves to the eyes and the face. 3. The mother washes the arms, chest, and back followed by the neck, arms, and face. 4. The mother washes the entire newborn's body and then washes the eyes, face, and scalp.

1 Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next the external ears and behind the ears are cleaned. The newborn's neck should be washed because formula, lint, or breast milk often accumulates in the folds. Hands and arms are next, then the legs, with the diaper area washed last.

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique should the nurse anticipate being used to check for evidence of birth trauma? 1. Palpating the clavicles for a fracture 2. Listening to the heart for a cardiac defect 3. Blanching the skin for the evidence of jaundice 4. Performing Ortolani's maneuver for hip dislocation

1 Rationale: Because of the neonate's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Auscultating for cardiac defects is not related to birth trauma. Evidence of jaundice should not be present initially. Hip dislocation is congenital and is not caused by birth trauma. Developmental dysplasia of the hip (DDH) is more likely to occur with a breech presentation.

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother? 1. Increase the frequency of the breastfeeding. 2. Stop the breastfeedings and switch to bottle-feeding permanently. 3. Provide bottled-water feedings between the breastfeeding sessions. 4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.

1 Rationale: Breastfeeding should be initiated within 2 hours after birth and should be done every 2 to 3 hours thereafter. Supplementation with water does not reduce hyperbilirubinemia and should be discouraged because supplemental feedings with water do not promote stool excretion. The infant should not be fed less frequently. It is not necessary to stop breastfeeding permanently.

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action? 1. Notify the registered nurse of the finding. 2. Tell the mother and father that this may indicate spina bifida. 3. Assess for other associated anomalies and document carefully. 4. Recognize that this is normal in the neonate and continue with the bath.

1 Rationale: In this instance, the tuft of hair may be indicative of a spinal anomaly, and the nurse would notify the registered nurse because the primary health care provider should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this role is the responsibility of the primary health care provider if an anomaly is suspected or diagnosed. The nurse should take the priority intervention of notifying the primary health care provider before documenting in the chart.

A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching? 1. "I need to bathe my newborn after a feeding." 2. "I will never leave the newborn in the tub of water alone." 3. "I will gather all my supplies before I start bathing my newborn." 4. "I need to fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the w

1 Rationale: It is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the newborn, before feeding may be the best time. Options 2, 3, and 4 are appropriate interventions in bathing a newborn.

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

1 Rationale: The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Explaining equipment is important but is not specific to parent-newborn bonding activities. Identifying specific care giving tasks to be assumed by the parents may be frightening because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate as the newborn's condition becomes stable. Providing pamphlets related to the newborn's condition is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best? 1. Document the findings. 2. Notify the registered nurse immediately. 3. Obtain a specimen of the discharge for culture. 4. Review the mother's record to determine a history of gonorrhea.

1 Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick, white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones.

The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which? 1. "I will observe for signs of bleeding with each diaper change." 2. "I will gently remove the yellow exudate from my child's penis." 3. "I will use soap to cleanse my child's penis 48 hours after circumcision." 4. "I will wash the penis vigorously with warm water to remove urine and feces."

1 Rationale: The glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. The mother should not attempt to remove it. Soap should be used only after the circumcision is healed (5 to 6 days). The circumcision should be checked for bleeding with each diaper change. The penis should be washed gently with warm water to remove urine and feces.

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

1 Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS.

Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply. 1. Monitor the temperature frequently. 2. Protect the eyes with an opaque mask. 3. Apply lotion generously to the body and extremities. 4. Remove all clothing from the newborn including diapers. 5. Monitor and document the number and consistency of stools.

1, 2, 5 Rationale: Phototherapy can cause changes in the newborn's temperature Therefore, the temperature should be closely monitored. The newborn's eyes are protected by an opaque eye mask to prevent overexposure to the light. The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools. Lotion should not be used during phototherapy because it absorbs heat and can cause burns. The newborn is unclothed, but a diaper is left on to protect the genitals.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply. 1. The newborn is irritable. 2. The newborn is lethargic. 3. The newborn cuddles easily. 4. The newborn cries incessantly. 5. The newborn is difficult to console. 6. The newborn hyperextends and postures

1, 4, 5 Rationale: A newborn born to a woman using drugs is irritable and is easily overloaded by sensory stimulation. The newborn may cry incessantly and be difficult to console. The newborn would not be lethargic and would hyperextend and posture rather than cuddle when being held.

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1. Urinary output 2. Blood glucose level 3. Total bilirubin level 4. Hemoglobin and hematocrit levels

2 Rationale: The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce central nervous system abnormalities and cognitive impairment if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the post-term neonate may exhibit polycythemia; however, this also does not require immediate attention.

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test? 1. Serum insulin level 2. Heel stick blood glucose 3. Rh and ABO blood typing 4. Indirect and direct bilirubin levels

2 Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage because of inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually prescribed after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for prescribing an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Serum insulin levels are not helpful because there is no intervention to decrease these levels in order to prevent hypoglycemia.

The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding? 1. Increase oral fluids. 2. Document the finding. 3. Notify the primary health care provider. 4. Assess blood pressure readings every 4 hours for the next 24 hours.

2 Rationale: During the first week after giving birth, transient episodes of bradycardia are common in the mother. The woman's pulse may be as low as 40 to 50 beats/min the first 1 to 2 days after delivery. It is not necessary to notify the primary health care provider. Increasing oral fluids, notifying the primary health care provider and performing numerous blood pressure screenings are not necessary.

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

2 Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? 1. A length of 19 inches 2. Abnormal palmar creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational ag

2 Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action? 1. Touch the cheek with a finger. 2. Clap the hand or slap on the mattress. 3. Stimulate the ball of the foot by firm pressure. 4. Stimulate the pads of the hands by firm pressure.

2 Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by touching the cheek area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure and the palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure.

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription? 1. Use the dorsogluteal muscle. 2. Obtain written parental consent. 3. Select a 21-gauge, 1-inch needle. 4. Spread the skin under the injection site.

2 Rationale: The nurse must obtain informed consent from the parents before administering the hepatitis B vaccine to the newborn. The vastus lateralis muscle is used because the dorsogluteal muscle is underdeveloped in the newborn and is dangerously close to the sciatic nerve. In addition, the dorsogluteal site is no longer an acceptable injection location even for adults. A 25-gauge, ½-inch needle is used. The nurse pinches up the skin to inject the medication.

A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication? 1. Anemia 2. Macrosomia 3. Hyperglycemia 4. Postmaturity syndrome

2 Rationale: Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore, excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers usually are delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly associated with infants of diabetic women.

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply. 1. Place bassinets 1 foot apart in the nursery. 2. Adhere to standard precautions during delivery and in the nursery. 3. Place an identification bracelet on the infant only after the initial bath is completed in the nursery. 4. Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5. Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

2, 4, 5 Rationale: Newborn safety and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines are always followed to prevent transmission of bacteria and other illnesses to infants. Safety precautions to prevent infant abduction include foot printing the infant along with fingerprinting the mother on the identification card, as well as placing bracelet identification on the mother and infant immediately following delivery. Educating parents to only release their infant to those wearing proper identification is key in preventing infant abductions in the inpatient situation. Bassinets are to be 3 feet apart, not 1 foot apart.

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which should be the priority concern? 1. Pain 2. Infection 3. Aspiration 4. The parents' concerns

3 Rationale: Because TEF manifests itself with regurgitation and coughing, the concern that has the highest priority is aspiration. Although the other problems are an important part of care, the one with the highest concern relates to airway.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem? 1. Sepsis 2. Hypercalcemia 3. Drug withdrawal 4. Intraventricular hemorrhage

3 Rationale: Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased use of calories). This response and the signs and symptoms of drug withdrawal seem to be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular hemorrhage are characterized by symptoms of CNS depression.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)? 1. Length 19 inches 2. Birth weight 6 pounds 14 ounces 3. Microcephaly and increased respiratory effort 4. Head circumference appropriate for gestational age

3 Rationale: Features associated with FAS include craniofacial abnormalities, cleft lip or palate, abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies, and increased respiratory effort during the transition to extrauterine life also are noted frequently in the neonate with FAS.

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my newborn a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3 Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers? 1. If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2. All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3. Clean around the cord with plain water as needed until the cord falls off. 4. Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain.

3 Rationale: The cord and base should be cleaned with plain water two or three times a day (per primary health care provider prescription). The steps are to lift the cord, wipe around the cord starting at the top, clean the base of the cord, and fold the diaper below the umbilical cord to allow the cord to air dry. Continuation of cord care is necessary until the cord falls off in 7 to 14 days. The baby does not feel pain in this area. The use of soap is not necessary.

In providing initial care to the newborn following delivery, what is the nurse's priority action? 1. Identify gestational age. 2. Identify the infant and mother. 3. Turn the infant's head to the side. 4. Record the number of umbilical vessels.

3 Rationale: The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action? 1. Covering the bladder with Tegaderm 2. Covering the bladder with a dry, sterile dressing 3. Covering the bladder with a sterile, nonadhering moist dressing 4. Applying sterile water soaks and a dry, sterile dressing to the mucosa

3 Rationale: The priority nursing intervention right after birth of a neonate with exstrophy of the bladder is to prevent infection of the sac. Infection of the sac can result if the sac leaks. This can be prevented by keeping the sac moist and covered. It is also imperative that the covering be of a nonadhering type.

The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

3 Rationale: There are 4 modes of heat loss. Conduction is loss of body heat to cooler surfaces that are in direct contact with the skin. Radiation is loss of body heat to a cooler surface that is not in direct contact with the skin. Convection is loss of heat from the body surface to cooler ambient air. Evaporation is loss of heat when liquid is converted to a gas.

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first? 1. Feed the infant. 2. Let the infant sleep. 3. Check the blood glucose level. 4. Call the primary health care provider immediately.

3 Rationale: This infant has classic symptoms of hypoglycemia. The nurse should plan to check the infant's blood glucose to determine the extent of hypoglycemia, if any, and then to take action by calling the primary health care provider and feeding the infant as per agency policy. Allowing the infant to sleep may cause the hypoglycemia to remain untreated and result in neurological damage.

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care? 1. Set up a phototherapy unit. 2. Prepare for an exchange transfusion. 3. Ask about the newborn's blood type and direct Coombs. 4. Administer an injection of vitamin K to prevent isoimmunization

3 Rationale: To further assess and plan for the newborn's care, the newborn's blood type and direct Coombs must be known. If the newborn's blood type is Rh negative, or if the newborn's blood type is Rh positive with a negative direct Coombs' test, then there is no concern for Rh incompatibility. If the newborn's blood type is Rh positive and the direct Coombs is positive, then Rh incompatibility exists. Options 1 and 2 are inappropriate at this time because additional data are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease in the newborn.

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becoming jaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

3 Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundice

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1. Use only baby wipes to cleanse the penis. 2. Remove the yellow exudate which forms by 24 hours post circumcision. 3. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the pro

3, 4, 5 Rationale: The glans penis is normally dark red. Use only water to cleanse the glans penis until complete healing has occurred around day 5 to 6. Diapers should be changed at least every 4 hours to inspect the glans penis for drainage or signs of infection. After circumcision, a small amount of bloody drainage is expected. Baby wipes may contain alcohol and should not be used to cleanse the glans penis. During the normal healing process, the glans becomes covered with a yellow exudate. This exudate should not be removed. If excessive bleeding is noted from the circumcision, the parent should be instructed to apply gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the primary health care provider is notified because a blood vessel may need to be ligated

The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply. 1. Tachycardia 2. Hyperactivity 3. Mottling of skin 4. Increased skin temperature 5. Increased respirations with apnea

3, 5 Rationale: Signs of cold stress include decreased skin temperature, increased respiratory rate with periods of apnea, bradycardia, mottling of skin, and lethargy. Recall that neonates are unable to shiver and will use up glucose in an effort to produce heat.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? 1. Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2. Protects the neonate's eyes from possible infections acquired while hospitalized 3. Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

4 Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes of administering this medication to the newborn.

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action? 1. Wrapping the newborn in a blanket 2. Closing the doors to the delivery room 3. Drying the newborn with a warm blanket 4. Warming the crib pad before placing the newborn in the crib

4 Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn's body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline? 1. Facial jaundice is common from birth to 5 days of age. 2. Bilirubin is produced at minimal rates in the neonate immediately following delivery. 3. The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery. 4. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

4 Rationale: Neonatal bilirubin levels below 12 mg/dL on the second to seventh day following birth are considered normal in the full-term neonate. The amount of the enzyme necessary for the conjugation of bilirubin may be decreased. Additionally, the delayed passage through the gastrointestinal tract and the rapid production of bilirubin from the breakdown of excess fetal red blood cells may lead to rising levels of unconjugated bilirubin and jaundice in the neonate.

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client? 1. Breastfeeding for 6 months 2. Breastfeeding for 9 months 3. Bottle-feeding with a fortified formula 4. Bottle-feeding with a tolerated formula

4 Rationale: Perinatal transmission of HIV can occur during the antenatal period, during labor and birth, or in the postpartum period if the client is breastfeeding. This information will help the client choose a feeding method that will support parenting and the normal physiological development of her infant. Bottle-feeding represents the best choice when considering current knowledge of HIV transmission during pregnancy. A fortified formulation is not indicated by the data supplied in the question.

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1. Alcohol is the only agent used to clean the cord. 2. It takes 21 days for the cord to dry up and fall off. 3. Cord care is done only at birth to control bleeding. 4. The process of keeping the cord clean and dry will decrease bacterial growth.

4 Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord.

The nurse is collecting initial data on a newborn in the delivery room. Which observations should the nurse expect to note in a healthy newborn? Select all that apply. 1. Sunken anterior fontanel 2. Appearance of facial jaundice 3. Heart rate of 80 beats per minute 4. Respiratory rate of 40 breaths/minute 5. Three umbilical cord vessel, two arteries and one vein

4, 5 Rationale: Normal respiratory rate of the newborn is 30 to 60 breaths/minute. The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. The anterior fontanel should not be sunken, which could indicate a state of dehydration. Developmental jaundice should not be present at birth. The heart rate should be minimally 100 beats/minute in the healthy newborn.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4, 5, 6 Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response? 1. Within acceptable ranges 2. Indicative of Rh incompatibility 3. Indicative of a need for phototherapy 4. Lower than normal for the newborn's age

Rationale: Many newborns exhibit jaundice in the newborn period. Total bilirubin levels tend to peak on the second and third days after birth. These levels are between 5 and 10 mg/dL in the healthy newborn. Option 2 is not correct because the range given is not elevated for a 2-day-old newborn, and there are no data to support an Rh incompatibility. Term newborns are not treated with phototherapy until their bilirubin is above 12 mg/dL.