N354 OB Mod 2 Review

Transient Tachypnea of Newborn (TTN)

-respiratory rate greater than 60 -usually resolves within 24 hours to a few days -due to retained lung field -may be present in full term infant or preemie -common in C-sections d/t excess fluid in lungs

Uric acid

-should resolve to normal urine color in diaper by day 5

Caput Succedaneum:

-swelling of soft tissues -may cross suture lines -resolves: goes from worse to better

Signs of Respiratory Distress:

-tachypnea (>60 resp/min) -cyanosis (circumoral cyanosis/general cyanosis) -nasal flaring -grunting (like a cat) -intercostal retractions -substernal retractions

APGAR Scoring:

-taken at 1 and 5 minutes after birth -taken again at 10 min if either score <7/10

How do we detect infection in newborns?

-temp LESS THAN 36.5 C (97.7 F) could indicate sepsis

Within 15-20 minutes after birth, how much of cardiac output goes to the lungs via the pulmonary artery in the fetus?

60% of CO

When do newborns get their final eye color?

9 months

Preterm

< 37 weeks gestation

Post dates

> 42 weeks gestation

What does a crying baby mean?

A crying baby is a BREATHING baby

Activity APGAR Scale:

0: Flaccid, limp 1: Some flexion of extremities 2: Good flexion, active motion

Anterior Fontanel:

-diamond shaped -closes by 18 months of age

breast milk

-loose -no odor -light yellow

Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A. Caput succedaneum B. Cephalohematoma C. Molding D. Depressed fontanelles

A. Caput succedaneum Explanation: Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction.

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A. Cephalohematoma B. Mongolian spots C. Telangiectatic nevi D. Molding

A. Cephalohematoma Explanation: A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. They may be associated with physiologic jaundice, because there are extra red blood cells being destroyed within the cephalohematoma.

Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism? A. Complement B. Coagulation C. Inflammatory response D. Phagocytosis

A. Complement Explanation: Complement helps or complements the ability of antibodies and phagocytic cells to clear pathogens from an organism.

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A. Place a gloved finger in the newborn's mouth. B. Take the vital signs. C. Wait until the newborn stops crying. D. Place a hot water bottle in the isolette.

A. Place a gloved finger in the newborn's mouth. Explanation: Vital sign assessments are most accurate if the newborn is at rest, so measure pulse and respirations first if the baby is quiet. To soothe a crying baby, the nurse should place a moistened, unpowdered, gloved finger in the babys mouth, and then complete the assessment while the baby suckles.

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. A. The fontanelles can swell with crying. B. The fontanelles might be depressed. C. The fontanelles can pulsate with the heartbeat. D. The fontanelles might bulge. E. The fontanelles can swell when stool is passed.

A. The fontanelles can swell with crying. C. The fontanelles can pulsate with the heartbeat. E. The fontanelles can swell when stool is passed. Explanation: 1. Newborn fontanelles can swell when the newborn cries and passes a stool and can pulsate with the heartbeat.

Which of the following would be considered normal newborn urinalysis values? Select all that apply. A. Color bright yellow B. Bacteria 0 C. Red blood cells (RBC) 0 D. White blood cells (WBC) more than 4-5/hpf E. Protein less than 5-10 mg/dL

B. Bacteria 0 C. Red blood cells (RBC) 0 E. Protein less than 5-10 mg/dL Explanation: Bacteria value should be 0. Red blood cells (RBC) should be 0. Protein less than 5-10 mg/dL would be considered normal.

Approximately what percentage of the newborn's body weight is water? A. 5% to 10% B. 90% to 95% C. 70% to 75% D. 50% to 60%

C. 70% to 75% Explanation: Approximately 70% to 75% of the newborn's body weight is water.

The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? A. 2 days B. 10 days C. 8 days D. 14 days

C. 8 days Explanation: The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborn's physician.

New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? A. The foreskin will be retractable at 2 months. B. Retract the foreskin and clean thoroughly. C. Avoid retracting the foreskin. D. Use soap and Betadine to cleanse the penis daily.

C. Avoid retracting the foreskin. Explanation: Foreskin will retract normally over time and may take 3 to 5 years.

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? A. Call the physician. B. Administer oxygen. C. Document the finding. D. Place the newborn under the radiant warmer.

C. Document the finding. Explanation: An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep.

The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? A. Notify the physician. B. Elevate the newborn's head. C. Document the findings in the chart. D. Assess for hypothermia immediately.

C. Document the findings in the chart. Explanation: Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm.

Which of the following is the primary carbohydrate in the breastfeeding newborn? A. Glucose B. Fructose C. Lactose D. Maltose

C. Lactose Explanation: Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed.

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? A. My baby might open her arms wide and pull her legs up to her tummy if she is passing gas. B. When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. C. When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on. D. I can get my baby to turn his head toward the right if I lift his right arm over his head.

C. When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on. Explanation: This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object.

AGA

appropriate for gestational age -middle 80%

Breast Milk Jaundice:

Often caused by a lack of sufficient intake -usually occurs at 3-7 days of life in a breastfeeding infant

Assessment of Fontanels:

Soft and flat: normal Full and bulging: increased intracranial pressure Depressed: dehydration

Why are C-section babies more spitty/mucus-y?

Swallowed amniotic fluid do not get pushed out during delivery unlike in vaginal deliveries

Critical Congenital Heart Defect (CCHD) test:

Pulse Ox is <95% in right hand and foot or >2% difference is abnormal

Normal Newborn heart rate:

Range: 110 - 160 BPM -count apical for 1 minute -murmur may be common (for the first 24 hours), but still follow-up -PMI often visible through chest

Normal Newborn respiratory rate:

Range: 30-60 BPM

Normal Newborn temperature (axillary only):

Range: 36.5 C to 37.5 C (97.7 F - 99 F)

Babinski reflex

Reflex in which a newborn fans out the toes when the sole of the foot is touched

When is general assessment of the newborn done?

done as soon as the baby is stabilized and placed on mom's abdomen or in the open warmer

transitional

greenish yellow

Meconium

greenish/black, tarry -usually passed 12-24 hrs

Within 24-48 hours after birth, how much of cardiac output goes to the lungs via the pulmonary arty in the fetus?

100% of CO (Ductus arteriosus must close for this to happen)

Methods of Heat Loss:

-Evaporation -Conduction -Convection -Radiation

Ears:

-recoil and pinna formation (gestational age) -angle of ear related to eye -low-set ears may be sign of chromosomal disorder -observe for ear pits and skin tags -baby's response to noise -hearing screen done prior to discharge

Evaporation:

-heat loss when water is converted to vapor -air drying of the skin that results in cooling

Causes of Pathologic jaundice:

-hemolytic disease of the newborn -neonatal sepsis -maternal disease

Newborn Weight:

-2500-4000 g (5 lb, 8 oz - 8 lb, 13 oz) -Average: 7 lb, 8 oz -expected to lose up to 10% of birth weight during first few days -normally regain or exceed birth weight by 14 days old

When the infant is heavily wrapped in blankets and in the prone position, how much of the total heat loss is through the face and head?

-85%

3 shunts that divert blood away from lungs and liver:

-Ductus venosus -Ductus arteriosus -Foramen ovale

Immediate Newborn Care at Delivery:

-Establish and maintain respirations -Prevent hypothermia/cold stress -Frequent assessment of respiration and color -Physical examination, vital signs -Identification

Most common types of circumcision:

-Gomco Clamp -Plastibell

Physiologic Jaundice:

-Occurs AFTER first 24 hours of life (usually days 2-4) as a result of hemolysis of RBCs and immaturity of the liver -most common type

Types of Jaundice (hyperbilirubinemia):

-Physiologic jaundice -pathologic jaundice -breast milk jaundice

Signs of Hyperthermia:

-Poor feeding -Hypotension -Apnea -Tachypnea -Diaphoresis -Irritability -Flushing -Tachycardia

Signs of Hypothermia:

-Poor feeding -Hypotonia -Apnea -Tachypnea -Lethargy -Acrocyanosis -Mottling -Bradycardia

Signs of inadequate thermoregulation:

-abnormal temps -poor feeding or feeding intolerance -irritability -lethargy -weak cry or suck -decreased muscle tone -cool skin temp -skin pale, mottled, or acrocyanotic -signs of hypoglycemia -signs of respiratory difficulty -poor weight gain

Jaundice Treatment:

-adequate feedings -infants treated with phototherapy require 25% more fluid intake -breastfeed at least every 2-3 hours -bottle feed at least every 3-4 hours -stimulate voiding and stooling -avoid water feeds b/c does not stimulate stool secretion -repeat blood bilirubin levels -high levels of bilirubin need phototherapy, IV fluids, and exchange transfusion

American Academy of Pediatrics Guidelines for Infant Sleep Safety & SIDS Risk Reduction:

-always place baby on his or her back for every sleep time -always use a firm sleep surface (not sitting) -room sharing but not bed-sharing -keep soft objects or loose bedding out of the crib -no pillows, blankets, and bumper pads -no wedges or positioners -pregnant woman should receive prenatal care -no smoking during pregnancy or after birth -breastfeeding is recommended -offer a pacifier at nap time and bedtime -avoid covering the infant's head or overheating -do not use home monitors or commercial devices marketed to reduce the risk of SIDS -receive all recommended vaccinations -supervised, awake tummy time daily to facilitate development and minimize positional plagiocephaly (flat heads)

Chorioamnionitis

-amniotic fluid infection -if infant involved, presents with fever, high heart rate, high respirations

Hypoglycemia protocol:

-assess in LGA, SGA, IDM, postterm, preterm, and symptomatic infants -if accucheck glucose levels LESS THAN 40 mg/dL, obtain venous blood glucose and feed infant or repeat accucheck to verify and breastfeed -repeat accucheck at 1, 3, and 6 hrs

Infant posterior assessment:

-assess spine for curvature -assess gluteal folds for symmetry -assess for spina bifida -observe for pilonidal dimple or tuft of hair (may signify spina bifida occulta)

How much output should a newborn have?

-at least 6 wet diapers/day by day 4 -1-5 stools but less with formula

Preventing Heat Loss through Radiation:

-avoid windows -use incubator door covers -double walled isolettes

Nose:

-babies are obligate nose breathers until 4 months or unless crying

Causes of hyperbilirubinemia:

-baby's inability to keep up with the rapid breakdown of RBCs -inability of the immature liver to conjugate bilirubin -bile duct obstruction -hemolytic disease of the newborn -traumatic birth injuries -delayed feeding/slow meconium excretion

Petechiae:

-benign if they disappear within 2 days of birth and no new lesions appear -sign of asphyxiation during birth or clotting disorder

Cephalhematoma:

-blood accumulation between skull and periosteum -does not cross suture line -usually seen within 24 hrs and may increase in size for 2-3 days (better to worse) -2-3 weeks to resolve

CDC recommendation of circumcision:

-can cut a man's risk of getting HIV from an infected female partner by 50-60% -reduce their risk of genital herpes and certain strains of human papillomavirus by 30% or more -lower the risk of UTI during infancy and cancer of the penis in adulthood

Breathing is initiated by:

-chemical (decrease in O2 and increase in CO2) -mechanical (fetal chest compression during vag birth) -thermal (skin temp sensory change)

Cord Care:

-clamped -ongoing assessment for infection -keep diaper folded under cord -per hospital/MD orders: alcohol, triple dye, goldenseal -air dry -no submerging tub bath until after cord has fallen off (usually 10-14 days)

Acrocyanosis

-cyanosis occurring in hands and feet -common in first 24 hours -exasperated by cold stress

Reasons for circumcision:

-disease risk reduction -cultural/religious factors -parental preference -lack of knowledge about care of the foreskin

Treatment of Hip dysplasia:

-double diaper -3-6 months in a harness and/or casting

Behavioral States:

-drowsy -quiet alert state (best for bonding) -active alert state (often fussy, restless) -crying

Preventing Heat Loss through Evaporation:

-dry at delivery -dry after bathing -keep linens dry -use K pads -use saran wrap blankets -use humidified air

Club feet

-due to lie of infant or congenital anomalies -not retractable to midline -treated with casting

Periods of reactivity:

-first period of reactivity 30 min - 2 hrs after birth: bonding/breastfeeding -period of sleep -second period of reactivity 4-6 hrs after birth; varied in duration)

Newborn Care Discharge Teaching:

-follow-up doctor's appointment: encourage parents to call MD if any questions/issues -breathing: irregular respirations, sneezing is normal, keep nose free of mucus -use of bulb syringe -temperature: dress infants one more layer than adults have on; feel trunk if hot or cold, intervene; call MD if temp is less than 97.7 or greater than 100 -output: at least 6 wet diapers/day by day 4; 1-5 stools (less with formula) -bathing: sponge bath until cord falls off, then can submerge; keep warm -handling the infant: head support; positions; wrapping; handwashing

Formula stools

-foul odor -more formed than breast milk stools -can be green, brown, light yellow

American Academy of Pediatrics (AAP) Recommendation:

-health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision

Newborn Screening Tests prior to discharge:

-hearing test -state newborn screening blood test for PKU (phenylketoneurea) and hypothyroidism as well as galactosemia, sickle cell disease, thalassemia -critical congenital heart defect

Risks of circumcision:

-hemorrhage -infection -removal of too much or too little -phimosis (tightening of the foreskin) -adhesions, necrosis -unsatisfactory cosmetic effect -urinary retention -urethral stenosis or fistula -injury to the glans -pain during and after surgery

When are blood pressures taken in newborns?

-if they appear to have circulation problems -unequal pulses -poor perfusion

Causes of physiologic jaundice:

-immature liver can not break down the RBCs that were necessary in utero, but are no longer necessary in such quantity as newborn is now breathing air -traumatic birth injuries (bruising, hematoma)

Methods of Heat production:

-increase activity -flexion -metabolism -vasoconstriction -nonshivering thermogenesis (brown fat)

Effects of cold stress:

-infants become restless -increase in muscular activity, and metabolism, increasing the need for oxygen -decreases production of surfactant, decreasing respiratory function -increases glucose for increased metabolism, putting the infant at risk for hypoglycemia -metabolism of brown fat releases fatty acids which can lead to metabolic acidosis and increases risk of jaundice

Common variations in respiratory rate:

-irregular, shallow, no distress -moist breath sounds may be present shortly after birth -periodic breathing is normal when LESS THAN 15-20 seconds

Circumcision teaching:

-keep area clean -change diaper with every void -wash penis with warm water -apply petroleum jelly with each diaper change -not tub bath until healed -report any abnormal discharge or redness -monitor for bleeding -apply gentle pressure with sterile gauze and call pediatrician

Why should we swaddle the infant?

-less likely to do the Moro Reflex -provides a sense of comfort

LBW

-low birth weight -2500 g or less

Classification of newborn stools:

-meconium -breast milk -transitional -formula stools

Newborn Immune System:

-neonates are less effective at fighting off infection than the older child or adult -IgG crosses the placenta in utero and provides a newborn with passive immunity -IgM and IgG are produced to protect against infection

Unconjugated bilirubin (indirect)

-not soluble in water -must be broken down by liver

Nursing responsibilities for circumcision:

-obtain signed consent -gather equipment -monitor for bleeding: a few drops of blood during first few diaper changes is normal -monitor for void (call if not within 6-8 hrs) -monitor for displacement of plastibell -teaching

Subgaleal hemorrhage:

-occurs when the emissary veins which connect the dural sinuses with the veins in the scalp rupture -serious complication that the infant can develop shortly after birth, and in many cases, it can be fatal -presence of fluctuance, ripple effect caused by the fluid buildup in the scalp -if the infant is on its back and the head is lifted off the bed, the fluid will pool towards the back of the scalp creating ripple effect

Characteristics of Post-term Babies:

-opaque skin -dry skin, cracked, peeling -long fingernails (may have scratches) -presence of reflexes -less presence of lanugo and vernix -body flexion (frog-like) -presence of plantar creases -well-formed ears with ready-recoil -presence of breast buds

Central cyanosis

-pale blue in thoracic area including extremities -may signal cardiac involvement

Hip dysplasia:

-partial or complete -tests: hip rotation feeling for "clicking" sound/feel -positive Barlow and/or Ortolani signs -assessment of symmetry of gluteal folds -assess of leg length -angle of hips symmetrical -breech babies more likely at risk

Factors that may affect parent-infant bonding:

-physical abnormalities of the baby may cause parents to shy away -critically ill infant -pain state of the mother -family dynamics of the baby's family -illness in the mother

Jaundice Assessment:

-physical assessment: yellowish discoloration of skin -check blanching of skin and color of sclera -progresses from head to toe -TCB: transcutaneous bilirubin -blood test: total serum bilirubin (TSB) -CBC, Coomb's test, reticulocyte count -for physiologic jaundice, the bilirubin peaks at 5 to 6 mg/dL between the 2nd and 4th days of life -should begin to fall , so that by 5-7 days, should be LESS THAN 2 mg/dL -charts help tell what is normal bilirubin level for infants depending on how many days old they are

Normal Skin Color in newborns:

-pink -warm -dry

Reflexes:

-plantar grasp -palmar grasp -rooting -sucking -gag -swallow -stepping -Moro (startle) -Babinski -Tonic neck

Plastibell:

-plastic rim to fall off within 5-8 days -yellow crust around area normal/do not remove/distinguish from infection

Neuromuscular characteristics assessed in the New Ballard Score:

-posture -square window -arm recoil -popliteal angle -scarf sign -heel to ear

Gomco Clamp:

-pressure of clamp for 3-5 minutes, then slit/cut away excess skin -petroleum gauze strips to site after to prevent sticking to diaper

Risk factors of TTN:

-preterm infants -maternal drug use -maternal infection -meconium in amniotic fluid

Preventing Heat Loss through Conduction:

-prewarm bedding -use a warmed scale -cover x-ray plates -warm the diapers -warm water -warm stethoscope

Interventions during phototherapy:

-protect eyes/genitals -reposition q 2 hrs

Bathing:

-provide when temperature is stable (usually >98 F) -sponge bath -tub bath -mild shampoo (Johnson & Johnson/Baby Magic) -Never leave child unattended -Assess skin for cuts, birthmarks, nevi, other

Ways to prevent heat loss:

-radiant warmer preparation -place infant on abdomen of mother immediately after birth -dry and remove wet linen -hat -warm anything that is applied directly to infant's skin -kangaroo care

Signs and symptoms of illness:

-temp greater than 38 C (100.4 F) or below 36.6 C (97.9 F) axillary -continual rise in temperature -forceful or frequent vomiting -refusal of two feedings in a row -difficulty in waking baby -cyanosis with or without feeding -absence of breathing > 20 sec -inconsolable infant or continuous high-pitched cry -discharge or bleeding from the umbilical cord, circumcision, or any opening -two consecutive green watery or black stools, or increased frequency of stools -no wet diaper for 18-24 hrs -fewer than 6-8 wet diapers per day after 4 days -development of eye drainage

Characteristics of Preterm Babies:

-thin, gelatinous skin -presence of superficial veins -absence of some reflexes -"floppier" muscle tone -extended body positioning -"floppy" ears/lack recoil -absence of plantar creases -presence of lanugo and vernix -males: undescended testes -females: "splayed"/open vulva

Posterior Fontanel:

-triangular shaped -smaller than the anterior fontanel -closes by 2 - 4 months of age

Causes of breast milk jaundice:

-unknown -theory: delayed or insufficient intake of breast milk

Reasons against circumcision:

-unnecessary surgery -culture: uncommon in some cultures -cutting part of a sexual part of the organ -cleanliness, especially during diapering period

How to suction airway if necessary:

-use bulb syringe, manual suction -MOUTH BEFORE NOSE

Newborn Chest Circumference:

-usually 2-3 cm smaller than the head -30-36 cm (12 - 14 inches)

VLBW

-very low birth weight -1500 g or less

Preventing Heat Loss through Convection:

-warm the environment -avoid drafts -cover the infant -use hats

Conjugated bilirubin (direct)

-water soluble -excreted in feces and urine

Pulses APGAR Scale:

0: Absent 1: <100 2: >100

Respirations APGAR Scale:

0: Absent 1: Slow, irregular, weak cry 2: Good, vigorous cry

Appearance APGAR Scale:

0: Blue 1: Acrocyanosis 2: Pink

Grimace APGAR Scale:

0: Not responsive 1: Weak cry and grimace 2: Vigorous cry, cough, and sneeze

Newborn visual field:

10 - 12 inches from face -can see faces and high color contrast

How much of cardiac output goes to the lungs via the pulmonary artery in the fetus?

15% of CO

Newborn Head Circumference:

32-38 cm (12.5 -15 inches)

When does the testes descend into the scrotum?

34 weeks gestation

When is sufficient surfactant produced?

34-36 weeks gestation

Term

37-42 weeks gestation

How much of the total oxygen consumption in infants is accounted for by the brain?

40% -it produces roughly that proportion of body heat

Newborn Length:

48-53 cm (19-21 inches)

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A. A normal position B. A possible chromosomal abnormality C. Facial paralysis D. Prematurity

A. A normal position Explanation: The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn.

A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? A. A quick cool bath will help wake up my son for feedings. B. I can check my son's temperature under his arm. C. My baby should be dressed warmly, with a hat. D. Cuddling my son will help to keep him warm.

A. A quick cool bath will help wake up my son for feedings. Explanation: Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal.

The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? A. A shift of intracellular water to extracellular spaces. B. Loss of meconium stool. C. A shift of extracellular water to intracellular spaces. D. The sleep-wake cycle.

A. A shift of intracellular water to extracellular spaces. Explanation: 1. A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss.

What condition is due to poor peripheral circulation? A. Acrocyanosis B. Mottling C. Harlequin sign D. Jaundice

A. Acrocyanosis Explanation: Acrocyanosis is a bluish discoloration of the hands and feet that may be present in the first 24 hours after birth and is due to poor peripheral circulation, which results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold.

The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. A. Administer a dose of 0.5 to 1 mg within 1 hour of birth. B. Administer the injection subcutaneously. C. Use a 25-gauge, 5/8-inch needle for the injection. D. Protect the medication bottle from light. E. Give vitamin K prior to a circumcision procedure.

A. Administer a dose of 0.5 to 1 mg within 1 hour of birth. C. Use a 25-gauge, 5/8-inch needle for the injection. D. Protect the medication bottle from light. E. Give vitamin K prior to a circumcision procedure. Explanation: 0.5 to 1 mg is the correct dosage for vitamin K. 25-gauge, 5/8-inch needle is the right size needle to use. Vitamin K must be kept away from light. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.

A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. A. Always place the infant in a supine position in the crib. B. Support the infant's head when carrying for the first week or two. C. Do not allow the baby to fall asleep in someone's arms. D. Cover the cord stump with a bandage. E. Use a bulb syringe to suction mucus from the infant's nostrils as necessary.

A. Always place the infant in a supine position in the crib. E. Use a bulb syringe to suction mucus from the infant's nostrils as necessary. Explanation: The newborn should be placed on his or her back (supine) for sleeping. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated.

Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A. Amount and area of vernix coverage B. Creases on the sole C. Size of the areola D. Body surface temperature

A. Amount and area of vernix coverage Explanation: Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn.

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? A. Arm recoil B. Square window sign C. Scarf sign D. Popliteal angle

A. Arm recoil Explanation: Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth.

A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to the parents. Which factors would the nurse include in the explanation? Select all that apply. A. At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. B. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. C. Unconjugated bilirubin results from the destruction of white blood cells. D. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. E. The newborn's liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborns susceptibility to jaundice.

A. At birth, the newborn's liver begins to conjugate bilirubin or convert it from a yellow lipid-soluble pigment to a water-soluble pigment. B. Unconjugated bilirubin can leave the bloodstream and enter the tissues, causing a yellow hue to the skin and sclera. D. The infant is able to excrete conjugated bilirubin, but not unconjugated bilirubin. Explanation: Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into water-soluble pigment (excretable, direct). Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Unconjugated bilirubin is fat soluble, has a propensity for fatty tissues, is not in an excretable form, and is a potential toxin.

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A. Brazelton Neonatal Behavioral Assessment Scale B. New Ballard Score C. Dubowitz gestational age scale D. Ortolani maneuver

A. Brazelton Neonatal Behavioral Assessment Scale Explanation: Brazelton Neonatal Behavioral Assessment Scale is an assessment tool that identifies the newborn's repertoire of behavioral responses to the environment and documents the newborns neurologic adequacy and capabilities.

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A. Chest circumference 31.5 cm, head circumference 33.5 cm B. Chest circumference 30 cm, head circumference 29 cm C. Chest circumference 38 cm, head circumference 31.5 cm D. Chest circumference 32.5 cm, head circumference 36 cm

A. Chest circumference 31.5 cm, head circumference 33.5 cm Explanation: The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size.

Marked changes occur in the cardiopulmonary system at birth include which of the following? Select all that apply. A. Closure of the foramen ovale B. Closure of the ductus venosus C. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns D. Increased systemic vascular resistance and decreased pulmonary vascular resistance E. Opening of the ductus arteriosus

A. Closure of the foramen ovale B. Closure of the ductus venosus D. Increased systemic vascular resistance and decreased pulmonary vascular resistance Explanation: 1. Closure of the foramen ovale is a function of changing arterial pressures. Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. Increased systemic vascular resistance and decreased pulmonary vascular resistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance.

The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. A. Continual rise in temperature B. Decreased frequency of stools C. Absence of breathing longer than 20 seconds D. Lethargy E. Refusal of two feedings in a row

A. Continual rise in temperature C. Absence of breathing longer than 20 seconds D. Lethargy E. Refusal of two feedings in a row Explanation: Parents should call their healthcare provider due to a continual rise in temperature, absence of breathing longer than 20 seconds, if the newborn exhibits lethargy and listlessness, and if the newborn has refused of two feedings in a row.

The mother of a newborn questions the nurse about the rash on the neck and chest of her 24-hour-old newborn. The lesions are discrete, 2-mm, white papules on a pink base. What term would the nurse use to define this finding? A. Erythema toxicum B. Milia C. Mongolian spots D. Telangiectatic nevus (stork bites)

A. Erythema toxicum

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? A. Eye prophylaxis medication B. Drying the newborn C. Vital signs D. Vitamin K injection

A. Eye prophylaxis medication Explanation: Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? A. Fewer infants require blood transfusion for anemia B. Fewer infants require blood transfusion for high blood pressure C. Increase in the incidence of intraventricular hemorrhage D. Increase in incidence of infant breastfeeding

A. Fewer infants require blood transfusion for anemia Explanation: Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia.

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. A. Gently massage the site after injection. B. Use a 22-gauge, 1-inch needle. C. Inject in the vastus lateralis muscle. D. Cleanse the site with alcohol prior to injection. E. Inject at a 45-degree angle.

A. Gently massage the site after injection. C. Inject in the vastus lateralis muscle. D. Cleanse the site with alcohol prior to injection. Explanation: The nurse would remove the needle and massage the site with an alcohol swab. Vitamin K is given intramuscularly in the vastus lateralis muscle. Before injecting, the nurse must clean the newborn's skin site for the injection thoroughly with a small alcohol swab.

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? A. Preeclampsia screening B. Congenital kidney disease screening C. Visual screening D. Hearing screening

D. Hearing screening Explanation: 4. Newborn screening tests include hearing screening tests.

The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Select all that apply. A. Habituation B. Motor activity C. Self-quieting activity D. Cuddliness E. Reflexes

A. Habituation B. Motor activity C. Self-quieting activity D. Cuddliness Explanation: Habituation is the newborn's ability to diminish or shut down innate responses to specific stimuli. The newborn's motor tone is assessed in the most characteristic state of responsiveness. Assessment is based on how often, how quickly, and how effectively newborns can use their resources to quiet and console themselves when upset or distressed. Cuddliness encompasses the infants need for and response to being held.

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A. His head is molded from fitting through the birth canal. It will become more round. B. We refer to that as cone head, which is a temporary condition that goes away. C. It might mean that your baby sustained brain damage during birth, and could have delays. D. I think he looks just like you. Your head is much the same shape as your baby's.

A. His head is molded from fitting through the birth canal. It will become more round. Explanation: This statement is accurate and directly answers the father's question.

The parents are asking the nurse about their newborn's behavior. The nurse begins to teach the parents about their newborn and involve them in their baby's care. What are these interventions directed at promoting to the parents? Select all that apply. A. Identification of responses or activities that best meet the special needs of their newborn. B. Ability to evaluate the neurologic capacity of their newborn. C. Understanding that the baby's temperament will be the same as their own. D. Positive attachment experiences. E. Understanding of the newborn's various behaviors.

A. Identification of responses or activities that best meet the special needs of their newborn. D. Positive attachment experiences. E. Understanding of the newborn's various behaviors. Explanation: Families learn which responses, interventions, or activities best meet the special needs of their newborn, and this understanding fosters positive attachment experiences. Parents usually need help in understanding the behaviors of their baby.

The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A. It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth. B. Bring your infant to the clinic immediately. C. This is due to overriding of the cranial bones during labor. D. Your baby must be dehydrated.

A. It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth. Explanation: This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks.

To maintain a healthy temperature in the newborn, which of the following actions should be taken?Select all that apply. A. Keep the newborn's clothing and bedding dry. B. Reduce the newborn's exposure to drafts. C. Do not use the radiant warmer during procedures. D. Do not wrap the newborn. E. Encourage the mother to snuggle with the newborn under blankets.

A. Keep the newborn's clothing and bedding dry. B. Reduce the newborn's exposure to drafts. E. Encourage the mother to snuggle with the newborn under blankets. Explanation: To maintain a healthy temperature in the newborn, keep the newborns clothing and bedding dry, reduce the newborn's exposure to drafts, and encourage the mother to snuggle with the newborn under blankets.

The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? A. Large amounts of uric acid crystals in the first days of life B. At least 6 to 10 wet diapers a day after the first few days of life C. 1 to 2 stools a day for formula-fed baby D. Urine that is straw to amber color without foul smell

A. Large amounts of uric acid crystals in the first days of life Explanation: Small, not large, amounts of uric acid crystals are normal in the first days of life.

Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? A. Massaging eyelids gently following application B. Irrigating eyes after instillation C. Using a syringe to apply ointment D. Instillation is in the upper conjunctival surface of each eye

A. Massaging eyelids gently following application Explanation: After administration, the nurse massages the eyelid gently to distribute the ointment.

The newborn's cry should have which of the following characteristics? Select all that apply. A. Medium pitch B. Shrillness C. Strength D. High pitch E. Lusty

A. Medium pitch C. Strength E. Lusty Explanation: The newborn's cry should be strong, lusty, and of medium pitch.

The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Select all that apply. A. More than one episode of forceful vomiting. B. More than 6 to 10 wet diapers per day. C. A bluish discoloration of the skin with or without a feeding. D. Refusal of two feedings in a row. E. Development of eye drainage.

A. More than one episode of forceful vomiting. C. A bluish discoloration of the skin with or without a feeding. D. Refusal of two feedings in a row. E. Development of eye drainage. Explanation: More than one episode of forceful vomiting or frequent vomiting over a 6-hour period, refusal of two feedings should be reported to the healthcare provider. Cyanosis (bluish discoloration of skin) with or without a feeding is a cause for concern, and should be reported to the healthcare provider immediately. The infant should not have eye drainage after discharge and this condition should be reported to the healthcare provider.

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A. Mother of a 2-week-old infant who doesn't make eye contact when talked to B. Father of a 1-week-old infant who sleeps through the noise of an older sibling C. Father of a 6-day-old infant who responds more to mother's voice than to father's voice D. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

A. Mother of a 2-week-old infant who doesn't make eye contact when talked to Explanation: This is an abnormal finding. Orientation to the environment is determined by an ability to respond to cues given by others and by a natural ability to fix on and to follow a visual object horizontally and vertically. Inability or lack of response may indicate visual or auditory problems.

When doing a neurologic assessment of a newborn, what would the nurse recognize? Select all that apply. A. Muscle tone is assessed by moving various parts of the newborn's body while the newborns head remains in a neutral position. B. The newborn is somewhat hypertonic. C. Muscle tone should be symmetrical. D. Shortly after birth, the infant is flaccid at rest. E. Diminished muscle tone requires further evaluation.

A. Muscle tone is assessed by moving various parts of the newborn's body while the newborns head remains in a neutral position. B. The newborn is somewhat hypertonic. C. Muscle tone should be symmetrical. E. Diminished muscle tone requires further evaluation. Explanation: Moving various parts of the newborn's body while the newborn's head remains in a neutral position is the correct way to assess muscle tone. The newborn will resist the examiner's attempts to extend the elbow and knee joints. Muscle tone should be symmetrical. If decreased muscle tone is noted, further evaluation is necessary.

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? A. My baby isn't getting enough iron from my breast milk. B. Babies undergo physiologic anemia of infancy. C. This results from dilution because of the increased plasma volume. D. Delaying the cord clamping did not cause this to happen.

A. My baby isn't getting enough iron from my breast milk. Explanation: At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron in the breast milk.

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didnt I see that he was so sick?" What is the nurse's best reply? A. Newborns have immature immune function at birth, and illness is very hard to detect. B. Your mothering skills will improve with time. You should take the newborn class. C. Your baby didn't get enough active acquired immunity from you during the pregnancy. D. The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old.

A. Newborns have immature immune function at birth, and illness is very hard to detect. Explanation: The immune responses in neonates are usually functionally impaired when compared with adults.

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Select all that apply. A. Newborns have less subcutaneous fat than do adults. B. Infants have a thick epidermis layer. C. Newborns have a large body surface to weight ratio. D. Infants have increased total body water. E. Newborns have more subcutaneous fat than do adults.

A. Newborns have less subcutaneous fat than do adults. C. Newborns have a large body surface to weight ratio. D. Infants have increased total body water. Explanation: Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonates decreased subcutaneous fat and large body surface to weight ratio. Preterm infants have increased heat loss via evaporation due to increased total body water.

When providing anticipatory guidance to a new mother, what information does the nurse convey about the newborn's neurologic and sensory/perceptual functioning? Select all that apply. A. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. B. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. C. Newborns do not react to bright light, and their eye movements do not permit them to fixate on faces or objects until they are 3 months of age. D. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. E. The newborn is very sensitive to being touched, cuddled, and held.

A. Newborns respond to and interact with the environment in a predictable pattern of behavior, reacting differently to a variety of stresses. B. The usual position of the newborn is with extremities partially flexed, legs near the abdomen. D. Newborns have the capacity to utilize self-quieting behaviors to quiet and comfort themselves. E. The newborn is very sensitive to being touched, cuddled, and held. Explanation: Newborns respond to and interact with the environment in a predictable pattern of behavior that is shaped somewhat by their intrauterine experience. Normal newborns are usually in a position of partially flexed extremities with the legs near the abdomen. Self-quieting ability is the ability of newborns to use their own resources to quiet and comfort themselves. The newborn is very sensitive to being touched, cuddled, and held; thus touch may be the most important of all of the senses for the newborn infant.

The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? A. Our baby was born with kidneys that are too small. B. A baby's kidneys don't concentrate urine well for several months. C. Feeding our baby frequently will help the kidneys function. D. Kidney function in an infant is very different from that in an adult.

A. Our baby was born with kidneys that are too small. Explanation: Size of the kidneys is rarely an issue.

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? A. Physiologic jaundice is normal, and peaks at this age. B. The newborn's liver is not working as well as it should. C. The baby is yellow because the bowels are not excreting bilirubin. D. The yellow color indicates that brain damage might be occurring.

A. Physiologic jaundice is normal, and peaks at this age. Explanation: Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants.

The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. A. Providing a pacifier B. Stroking the head C. Restraining both arms and legs D. Talking to the infant E. Giving the infant a sedative before the procedure

A. Providing a pacifier B. Stroking the head D. Talking to the infant Explanation: Providing a pacifier, stroking the head, and talking to the infant are accepted methods of soothing during the circumcision.

The New Ballard Score is used to:

Determine Gestational Age

The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following?Select all that apply. A. Respiratory rate B. Skin texture C. Airway clearance D. Ability to feed E. Head weight

A. Respiratory rate C. Airway clearance D. Ability to feed Explanation: The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate), airway clearance, and ability to feed.

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Select all that apply. A. Restlessness B. Pain C. Kidney distention D. Adequacy of fluid intake E. Lethargy

A. Restlessness B. Pain D. Adequacy of fluid intake Explanation: A newborn who has not voided by 48 hours after birth should be assessed for restlessness, pain, and adequacy of fluid intake.

The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Select all that apply. A. Sole creases B. Amount of breast tissue C. Amount of lanugo D. Reflexes E. Testicular descent

A. Sole creases B. Amount of breast tissue C. Amount of lanugo E. Testicular descent Explanation: Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development.

Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. A. State of alertness B. Active posture C. Quality of muscle tone D. Cry E. Motor activity

A. State of alertness C. Quality of muscle tone D. Cry E. Motor activity Explanation: Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity.

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurses best response? A. Take your newborn to the pediatrician. B. Cover the cord stump with gauze. C. Apply Betadine around the cord stump. D. This is normal during healing.

A. Take your newborn to the pediatrician. Explanation: Parents should check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to healthcare provider any signs of infection.

Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. A. Teach by example and role modeling when caring for the newborn in the client's room. B. Teach at every opportunity, even during the night shift, if the occasion arises. C. Teach using newborn care videos and group classes. D. Teach using the 24-hour educational television channels in the clients room. E. Teach using one-to-one instruction while in the client's room.

A. Teach by example and role modeling when caring for the newborn in the client's room. B. Teach at every opportunity, even during the night shift, if the occasion arises. E. Teach using one-to-one instruction while in the client's room. Explanation: The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. One-to-one teaching while the nurse is in the clients room is shown to be the most effective educational model.

The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Select all that apply. A. The behavioral assessment should be done as soon after birth as possible. B. The behavioral assessment can be performed without input from parents. C. The behavioral assessment might be incomplete in a 1-hour home visit. D. The behavioral assessment includes orientation and motor activity. E. The behavioral assessment can detect neurological impairments.

A. The behavioral assessment should be done as soon after birth as possible. B. The behavioral assessment can be performed without input from parents. Explanation: Because the first few days after birth are a period of behavioral disorganization, the complete assessment should be done on the third day after birth. Parental input is required. It provides a way for the healthcare provider, in conjunction with the parents (primary caregivers), to identify and understand the individual newborns states, temperament, capabilities, and individual behavior patterns.

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? A. The infant's mother has group B streptococcal (GBS) disease. B. The infant's mother had an IV of lactated Ringers solution. C. The infant's mother had a labor that lasted 12 hours. D. The infant's mother had a cesarean birth with her last child.

A. The infant's mother has group B streptococcal (GBS) disease. Explanation: A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis.

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? A. The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion. B. The infant received too many red blood cells after delivery because the cord was not clamped immediately. C. The yellow color of your baby's skin indicates that you are breastfeeding too often. D. This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should.

A. The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion. Explanation: Physiologic jaundice is a common occurrence, and peaks at 3 to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the livers ability to conjugate bilirubin and increases susceptibility to jaundice.

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics?Select all that apply. A. The mass appeared on the second day after birth. B. The mass appears larger when the newborn cries. C. The head appears asymmetrical. D. The mass appears on only one side of the head. E. The mass overrides the suture line.

A. The mass appeared on the second day after birth. D. The mass appears on only one side of the head. Explanation: A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days and can be unilateral or bilateral, but do not cross the suture lines.

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. A. The medication should be instilled in the lower conjunctival sac of each eye. B. The eyelids should be massaged gently to distribute the ointment. C. The medication must be given immediately after delivery. D. The medication does not cause any discomfort to the infant. E. The medication can interfere with the baby's ability to focus.

A. The medication should be instilled in the lower conjunctival sac of each eye. B. The eyelids should be massaged gently to distribute the ointment. E. The medication can interfere with the baby's ability to focus. Explanation: Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. After administration, the nurse massages the eyelid gently to distribute the ointment. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborns weight? A. This weight loss is excessive. B. This weight loss is within normal limits. C. This weight gain is excessive. D. This weight gain is within normal limits.

A. This weight loss is excessive. Explanation: This newborn has lost more than 10% of the birth weight; this weight loss is excessive. Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns.

Most newborns void in the first 24 hours after birth. The nurse interprets that which of the following is responsible for a reddish stain sometimes called "red brick spots" or "brick deposits," on the newborn's diaper? A. Uric acid crystals in the urine B. Mucus and urate in the urine C. Excess bilirubin in the urine D. Excess iron in the urine

A. Uric acid crystals in the urine

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? A. Your baby will respond to you the most if you look directly into his eyes and talk to him. B. Each baby is different. Don't try to compare your infant's behavior with any other child's behavior. C. If the sound level around your baby is high, the baby will wake up and be fussy or cry. D. If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy.

A. Your baby will respond to you the most if you look directly into his eyes and talk to him. Explanation: The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them.

APGAR:

A: Appearance (skin color) P: Pulses G: Grimace (reflex irritability) A: Activity (muscle tone) R: Respirations

The nurse is teaching new parents how to dress their newborn. Which statement(s) would indicate that teaching has been effective? Select all that apply. A. "We should keep our home air-conditioned so the baby doesn't overheat." B. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C. "When we change the baby's diaper, we should change any wet clothing or blankets, too." D. "If the baby's body temperature gets too low, he will warm himself up without any shivering." E. "Our baby will have a much faster rate of breathing if he is dressed too warmly."

B. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C. "When we change the baby's diaper, we should change any wet clothing or blankets, too." E. "Our baby will have a much faster rate of breathing if he is dressed too warmly."

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? A. Keep the baby in the room at all times. B. Check the identification of all personnel who transport the newborn. C. Place a No Visitors sign on the door. D. Keep the baby in the nursery at all times.

B. Check the identification of all personnel who transport the newborn. Explanation: Parent should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance.

Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Select all that apply. A. Use triple-dye to cleanse the umbilical cord at home. B. Fold the diaper down to prevent covering the cord stump. C. Keep the umbilical stump clean and dry to avoid infection. D. Observe for signs of infection such as foul smell, redness, and drainage. E. Begin tub baths to help cleanse the cord stump at home.

B. Fold the diaper down to prevent covering the cord stump. C. Keep the umbilical stump clean and dry to avoid infection. D. Observe for signs of infection such as foul smell, redness, and drainage. Explanation: Folding the diaper down to prevent coverage of the cord stump can prevent contamination of the area and promote drying. Keeping the umbilical stump clean and dry can reduce the risk of infection. It is the nurse's responsibility to instruct parents in caring for the cord and observing for signs and symptoms of infection after discharge, such as foul smell, redness and greenish yellow drainage, localized heat and tenderness, or bright red bleeding or if the area remains unhealed 2 to 3 days after the cord has sloughed off.

When assessing a full-term newborn, the nurse notes tremor-like movements. The nurse is aware that further evaluation is indicated to rule out which of the following? Select all that apply. A. Hyperglycemia B. Hypoglycemia C. Hypocalcemia D. Substance withdrawal E. Neurologic damage

B. Hypoglycemia C. Hypocalcemia D. Substance withdrawal E. Neurologic damage Explanation: Tremors or jitteriness (tremor-like movements) in the full-term newborn must be evaluated to differentiate the tremors from convulsions. Tremors may be related to hypoglycemia, hypocalcemia, or substance withdrawal. Neurologic damage should also be considered if the newborn is experiencing tremors.

Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extra-uterine environment. Which information is pertinent to this assessment? Select all that apply. A. Drug or alcohol use by the father B. Infectious disease screening results C. Maternal history of gestational diabetes D. Prolonged rupture of the membranes E. Maternal use of prenatal vitamins

B. Infectious disease screening results C. Maternal history of gestational diabetes D. Prolonged rupture of the membranes Explanation: Infectious disease screening results help to determine if the infant is also at risk of obtaining any infectious diseases. Gestational diabetes is a risk factor for the newborn. Prolonged rupture of the membranes is a possible risk factor for the infant.

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. A. We should keep our home air-conditioned so the baby doesn't overheat. B. It is important that we dry the baby off as soon as we give him a bath or shampoo his hair. C. When we change the baby's diaper, we should change any wet clothing or blankets, too. D. If the baby's body temperature gets too low, he will warm himself up without any shivering. E. Our baby will have a much faster rate of breathing if he is not dressed warmly enough.

B. It is important that we dry the baby off as soon as we give him a bath or shampoo his hair. C. When we change the baby's diaper, we should change any wet clothing or blankets, too. D. If the baby's body temperature gets too low, he will warm himself up without any shivering. E. Our baby will have a much faster rate of breathing if he is not dressed warmly enough. Explanation: The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through which heat is produced. A decrease in the environmental temperature of 2 C is a drop sufficient to double the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress.

The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A. Adducting the foot and listening for a click. B. Moving the foot to midline and determining resistance. C. Extending the foot and observing for pain. D. Stimulating the sole of the foot.

B. Moving the foot to midline and determining resistance. Explanation: Clubfoot is suspected when the foot does not turn to a midline position or align readily.

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? A. My baby will be able to focus on my face when she is about a month old. B. My baby might startle a little if a loud noise happens near him. C. Newborns prefer sour tastes. D. Our baby wont have a sense of smell until she is older.

B. My baby might startle a little if a loud noise happens near him. Explanation: Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex are other ways to soothe the newborn. The settled newborn is then able to attend to and interact with the environment.

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? A. Keep the infant NPO for 4 hours following the procedure. B. Observe for urine output. C. Wrap dry gauze tightly around the penis. D. Clean with cool water with each diaper change.

B. Observe for urine output. Explanation: It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema.

The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? A. Habituation B. Orientation C. Self-quieting D. Reactivity

B. Orientation Explanation: Orientation is the newborn's ability to be alert to, to follow, and to fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shiny objects.

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? A. I will call your pediatrician immediately. B. Passage of the first stool within 48 hours is normal. C. Your newborn might not have a stool until the third day. D. Your newborn must be dehydrated.

B. Passage of the first stool within 48 hours is normal. Explanation: The first voiding should occur within 24 hours and first passage of stool within 48 hours.

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. A. Respiratory rate of 66 breaths per minute B. Periodic breathing with pauses of 25 seconds C. Synchronous chest and abdomen movements D. Grunting on expiration E. Nasal flaring

B. Periodic breathing with pauses of 25 seconds D. Grunting on expiration E. Nasal flaring Explanation: Periodic breathing with pauses longer than 20 seconds (apnea), grunting on expiration, and nasal flaring are abnormal findings that should be reported to the physician.

In utero, what is the organ responsible for gas exchange? A. Umbilical vein B. Placenta C. Inferior vena cava D. Right atrium

B. Placenta Explanation: In utero, the placenta is the organ of gas exchange.

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? A. Nevus vasculosus B. Nevus flammeus C. Telangiectatic nevi D. A Mongolian spot

C. Telangiectatic nevi Explanation: Telangiectatic nevi (stork bites) appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck.

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. A. Lanugo abundant over shoulders and back B. Plantar creases over entire sole C. Pinna of ear springs back slowly when folded. D. Vernix well distributed over entire body E. Testes are pendulous, and the scrotum has deep rugae

B. Plantar creases over entire sole E. Testes are pendulous, and the scrotum has deep rugae Explanation: Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae.

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? A. Lanugo mainly gone, little vernix across the body B. Prominent clitoris, enlarging minora, anus patent C. Full areola, 5 to 10 mm bud, pinkish-brown in color D. Skin opaque, cracking at wrists and ankles, no vessels visible

B. Prominent clitoris, enlarging minora, anus patent Explanation: At 30 to 32 weeks gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris.

The nurse assesses a sleeping 1-hour-old, 39-weeks-gestation newborn. The assessment data that would be of greatest concern would be which of the following? A. Temperature 97.9F B. Respirations 68 breaths/minute C. Vital signs stable for only 2 hours D. Heart rate 156 beats/min

B. Respirations 68 breaths/minute Explanation: The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? A. Jaundice is uncommon in newborns. B. Some newborns require phototherapy. C. Jaundice is a medical emergency. D. Jaundice is always a sign of liver disease.

B. Some newborns require phototherapy. Explanation: Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy.

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? A. Heart rate 120 B. Temperature 96.8 F C. Respiratory rate 50 D. Temperature 99.6 F

B. Temperature 96.8 F Explanation: The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the baby's axillary temperature is below 36.5 C (97.7 F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia.

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A. I'm checking to make sure the baby has all of its parts. B. This assessment looks at both physical aspects and the nervous system. C. This assessment checks the baby's brain and nerve function. D. Don't worry. We perform this check on all the babies.

B. This assessment looks at both physical aspects and the nervous system. Explanation: Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations.

The nurse is working with a mother who has just delivered her third child at 33 weeks gestation. The mother says to the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" What is the best response by the nurse? A. Every baby is different. This is just one variation of normal that we see on a regular basis. B. This baby might not have a rooting or sucking reflex because she is premature. C. When she is wide awake and alert, she will probably root and suck even if she is early. D. She might be too tired from the birthing process and need a couple of days to recover.

B. This baby might not have a rooting or sucking reflex because she is premature. Explanation: Preterm babies may have suppressed or absent root and suck reflexes.

Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? A. 6 to 12 hours after birth B. Within 1 hour of birth C. 24 hours after birth D. 48 hours after birth

B. Within 1 hour of birth Explanation: Breastfeeding should be initiated within the first hour of life unless medically contraindicated.

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? A. Excessive B. Within normal limits C. Less than expected D. Unusual

B. Within normal limits Explanation: This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life.

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? A. Don't worry. Babies go through a lot of these little phases. B. Your son is in the sleep phase. He'll wake up soon. C. Your son is exhausted from being born, and will sleep 6 more hours. D. Your breastfeeding efforts have caused excessive fatigue in your son.

B. Your son is in the sleep phase. He'll wake up soon. Explanation: The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half an hour, the newborn's activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours.

Pathologic Jaundice:

Begins DURING first 24 hours -may require treatment with phototherapy -usually does not respond to phototherapy alone but will be treated initially with this treatment -persistent jaundice after the first week of life in term infant -persistent jaundice after the first 2 weeks of life in PREterm infant

The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A. Wrap the diaper tightly. B. Clean with warm water with each diaper change. C. Apply gentle pressure to the site with gauze. D. Apply a new petroleum ointment gauze dressing.

C. Apply gentle pressure to the site with gauze. Explanation: If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider.

The nurse administers vitamin K to the newborn for what reason? A. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient B. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection C. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract D. The supply of vitamin K is inadequate for at least 3-4 months, and the newborn must be supplemented

C. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract

Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. A. African American ethnicity B. Female gender C. Cephalohematoma D. Bruising E. Assisted delivery with vacuum or forceps

C. Cephalohematoma D. Bruising E. Assisted delivery with vacuum or forceps Explanation: A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma, bruising, and assisted delivery with vacuum or forceps.

The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? A. Circumcision should be undertaken to prevent problems in the future. B. Circumcision might decrease the child's risk of developing a urinary tract infection. C. Circumcision can sometimes cause complications. What questions do you have? D. Circumcision is painful, and should be avoided unless you are Jewish.

C. Circumcision can sometimes cause complications. What questions do you have? Explanation: Asking this question allows the nurse to determine what the parents' concerns are, then address them specifically.

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? A. Ortolani maneuver B. Palmar grasping reflex C. Clavicle D. Tonic neck reflex

C. Clavicle Explanation: When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture.

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? A. Placing the newborn away from air currents B. Pre-warming the examination table C. Drying the newborn thoroughly D. Removing wet linens from the isolette

C. Drying the newborn thoroughly Explanation: The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical.

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infants gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C. Ear cartilage folded over, lanugo present over much of the body, slow recoil time D. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

C. Ear cartilage folded over, lanugo present over much of the body, slow recoil time Explanation: Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant.

The maternal-newborn nurse formulates which nursing goal for a newborn in transition within the first few hours after birth to: A. Facilitate development of a close parent-infant relationship B. Assist parents in developing healthy attitudes about childbearing practices C. Identify actual or potential problems that may require immediate or emergency attention D. Provide the parents of the newborn with information about well-baby programs

C. Identify actual or potential problems that may require immediate or emergency attention

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? A. I can't believe he can already digest fats, carbohydrates, and proteins. B. It is amazing that his whole digestive tract can move things along at birth. C. Incredibly, his stomach capacity was already a cupful when he was born. D. He will lose some weight but then miraculously regain it by about 10 days.

C. Incredibly, his stomach capacity was already a cupful when he was born. Explanation: The newborns stomach has a capacity of 22 mL to 27 mL by day 3 of life.

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? A. Enable T or B cells to respond to antigens B. Repress responses to specific B or T lymphocytes to antigens C. Kill foreign or virus-infected cells D. Remove pathogens and cell debris

C. Kill foreign or virus-infected cells Explanation: Cytotoxic activated T cells kill foreign or virus-infected cells.

A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old baby's failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following? Select all that apply. A. Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding. B. Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt. C. Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal. D. Newborns lose a lot of heat, so make sure you keep the baby's formula warm when you supplement the breast milk. E. Keep the baby from getting chilled or too warm because that can contribute to weight loss.

C. Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal. E. Keep the baby from getting chilled or too warm because that can contribute to weight loss. Explanation: Newborns have a physiological weight loss of 5% to 10% in the first 3 or 4 days. Weight loss in the newborn can be caused by temperature elevation or consistent chilling.

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? A. Babies have several sleep and alert states. Keep watching and you'll notice them. B. You might have noticed that your child was in an alert awake state for an hour after birth. C. Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep. D. Birth is hard work for babies. It takes them a week or two to recover and become more awake.

C. Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep. Explanation: Teaching the parents how to recognize the two sleep stages helps them tune in to their infants behavioral states.

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? A. Stool characteristics B. Fluid intake C. Skin color D. Bilirubin level

C. Skin color Explanation: Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice.

The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? A. Hold the newborn in an upright position. B. Massage the hands and feet. C. Swaddle the newborn in a blanket. D. Make eye contact while talking to the newborn.

C. Swaddle the newborn in a blanket. Explanation: Swaddling or bundling the baby increases a sense of security and is a quieting activity.

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? A. 37-week male, respiratory rate 45 B. 8 pound 1 ounce female, pulse 150 C. Term male, nasal flaring D. 4-hour-old female who has not voided

C. Term male, nasal flaring Explanation: Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress.

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A. The white spots on my baby's nose are called milia, and are harmless. B. The whitish cheese-like substance in the creases is vernix and will be absorbed. C. The red spots with a white center on my baby are abnormal acne. D. Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician.

C. The red spots with a white center on my baby are abnormal acne. Explanation: Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary.

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? A. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. B. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

C. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. Explanation: Neonatal assessment proceeds in a head-to-toe fashion.

A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because: A. Their renal function is not fully developed, and heat is lost in the urine B. Their small body surface area favors more rapid heat loss than does an adult's body surface area C. They have a relatively thin layer of subcutaneous fat that provide poor insulation D. Their normal flexed posture favors heat loss through perspiration

C. They have a relatively thin layer of subcutaneous fat that provide poor insulation

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? A. Conjugated bilirubin is eliminated in the conjugated state. B. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. C. Total bilirubin is the sum of the direct and indirect levels. D. Hyperbilirubinemia is a decreased total serum bilirubin level.

C. Total bilirubin is the sum of the direct and indirect levels. Explanation: Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin.

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? A. 60 breaths per minute B. 70 breaths per minute C. 64 breaths per minute D. 20 breaths per minute

D. 20 breaths per minute Explanation: If respirations drop below 20 when the baby is at rest the primary care provider should be notified.

A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? A. 2 months B. 2 weeks C. 1 year D. 4 months

D. 4 months Explanation: Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months.

The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? A. 3-day-old male who received hepatitis B vaccine prior to discharge B. 4-day-old female whose parents are both hearing-impaired C. 5-day-old male with light, sticky, yellow drainage on the circumcision site D. 6-day-old female with greenish discharge from the umbilical cord site

D. 6-day-old female with greenish discharge from the umbilical cord site Explanation: Oozing of greenish yellow material, or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication.

The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse's response should be based on the knowledge that this is: A. Unacceptable because of the risk of sudden infant death syndrome (SIDS) B. Unacceptable because it does not encourage achievement of developmental milestones C. Acceptable because it encourages fine motor development D. Acceptable because it encourages head control and turning over

D. Acceptable because it encourages head control and turning over

The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? A. Sleep and alert states cycle throughout the day. B. We can best bond with our child during an alert state. C. About half of the baby's sleep time is in active sleep. D. Babies sleep during the night right from birth.

D. Babies sleep during the night right from birth. Explanation: Over time, the newborn's sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day.

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? A. You appear to be Muslim. Do you want your son circumcised? B. Let me explain newborn care here in the United States. C. Your baby is a United States citizen. You must be very happy about that. D. Could you explain your preferences regarding child-rearing?

D. Could you explain your preferences regarding child-rearing? Explanation: The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care.

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents learning. Which statement indicates that teaching was effective? A. Some babies are easier to deal with than others. B. We are lucky to have a baby with a calm disposition. C. Our baby spends more time in the active alert phase. D. Cuddliness is a social behavior that some babies have.

D. Cuddliness is a social behavior that some babies have. Explanation: According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality.

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? A. I should avoid looking directly into the baby's eyes to prevent frightening the baby. B. My baby will be very sleepy immediately after birth and should go to the nursery. C. Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby. D. Giving the baby his first bath can really give me a chance to get to know him.

D. Giving the baby his first bath can really give me a chance to get to know him. Explanation: Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their baby's behavior and the nurse can observe and point out behaviors.

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? A. Monitor urine for amount and characteristics. B. Encourage late feedings to promote intestinal elimination. C. All infants should be routinely monitored for iron intake. D. Maintain the newborns skin temperature at 36.5 C (97.8 F) or above..

D. Maintain the newborns skin temperature at 36.5 C (97.8 F) or above. Explanation: Maintain the newborns skin temperature at 36.5 C (97.8 F) or above; cold stress results in acidosis

A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborn's crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain? A. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. B. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. C. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. D. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

D. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder. Explanation: Habituation is the newborn's ability to diminish or shut down innate responses to specific repeated stimuli.

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? A. Respiratory rate 60 and irregular in depth and rhythm B. Pulse rate 145, cardiac murmur heard C. Mean blood pressure 55 mm Hg D. Pauses in respiration lasting 30 seconds

D. Pauses in respiration lasting 30 seconds Explanation: Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention.

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? A. Neonatal jaundice B. Neonatal hypothermia C. Neonatal hyperthermia D. Respiratory distress

D. Respiratory distress Explanation: Nasal flaring and facial grimacing are signs of respiratory distress.

The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A. Select videos on various topics of newborn care. B. Organize a class that includes first-time mothers only. C. Have mothers return in 1 week, when they feel more rested. D. Schedule time for one-to-one teaching in the mothers room.

D. Schedule time for one-to-one teaching in the mothers room. Explanation: One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions.

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B. When the corner of the mouth is touched, the infant turns the head that direction. C. The infant blinks when the exam light is turned on over the face and body. D. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

D. The right arm is flaccid while the infant brings the left arm and fist upward to the head. Explanation: Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. Muscle tone should be symmetric and diminished muscle tone and flaccidity requires further evaluation.

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurses best response? A. Take your newborn to the pediatrician. B. There might be a possible food allergy. C. Your newborn has diarrhea. D. This is a normal occurrence.

D. This is a normal occurrence. Explanation: The newborns stools change from meconium (thick, tarry, black) to transitional stools (thinner, brown to green).

The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? A. The baby should be in the back seat. B. Newborns must be in rear-facing car seats. C. We need instruction on how to use the car seat before installing it. D. We can bring the baby home from the hospital without a car seat as it is only a short drive home.

D. We can bring the baby home from the hospital without a car seat as it is only a short drive home. Explanation: Newborns must go home from the birthing unit in a car seat adapted to fit newborns.

The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? A. You are very young, and parenting will be a challenge for you. B. Your mother was probably right. Be very careful with your baby. C. Mothers have instincts that kick in when they get their babies home. D. We can give the baby's bath together. I'll help you learn how to do it.

D. We can give the baby's bath together. I'll help you learn how to do it. Explanation: This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.

The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? A. Call your pediatrician if the baby's temperature is below 98.6 F axillary. B. Your baby's stools will change to a greenish color when your milk comes in. C. You can wipe away any eye drainage that might form. D. Your infant should wet a diaper at least 6 times per day.

D. Your infant should wet a diaper at least 6 times per day. Explanation: A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake.

Vitamin K prophylaxis (Phytonadione)

Dose: 0.5 to 1.0 mg IM in vastus lateralis -Vitamin K normally produced by intestinal flora, but newborn GI tract is sterile, so Vitamin K given prophylactically -Assists with blood clotting -If not given within 2-3 days following birth, possible hemorrhages may occur

Choanal atresia

closure of nasal cavity due to congenital septum between nasal cavity and pharynx

To prevent heat loss through the face and head:

cover the infant's head

IUGR

intrauterine growth restriction

LGA

large for gestational age -top 10%

Conduction:

movement of heat away from the body when infants come in direct contact with objects cooler than their skin

SGA

small for gestational age -bottom 10%

Moro Reflex

startle reflex

Why do we not want babies to increase their heat production?

these factors increase oxygen and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice

Convection:

transfer of heat from the infant to cooler surrounding air

Radiation:

transfer of heat to cooler objects that are not in direct contact with the infant

cryptorchidism

undescended testicles

Red/golden stain in diapers indicate?

uric acid crystals

When should the first void occur?

within 24 hours -absence of stool or urine for 48 hours may signify an abnormality