NCLEX Neonatal
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? a. Inspect the clamp to insure that it is tightly closed and applied correctly. b. Clean the cord with soap and water, as oozing of blood is a common finding. c. Remove the clamp and replace with another one just above the old one. d. Notify the doctor to come suture the site of the bleeding.
a. Inspect the clamp to insure that it is tightly closed and applied correctly. Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next? a. Obtain a transcutaneous bilirubin level. b. Draw blood for a metabolic panel. c. Prepare the infant for an exchange transfusion. d. Initiate phototherapy.
a. Obtain a transcutaneous bilirubin level. Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn? a. Toes fan out when sole of foot is stroked. b. Infant throws arms outward and flexes knees. c. Infant makes stepping motion. d. Infant's toes curl over the nurse's finger.
a. Toes fan out when sole of foot is stroked. The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? a. Instill 0.5% ophthalmic silver nitrate. b. Instill 0.5% ophthalmic tetracycline. c. Instill 0.5% ophthalmic erythromycin. d. Watch for signs of eye irritation.
c. Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as: a. potential for respiratory distress. b. poor oxygenation. c. cold stress. d. acrocyanosis.
d. acrocyanosis. Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.