NEWBORN 33-4
The nurse is teaching a postpartum patient on the normal stooling pattern of a newborn. Which patient statement indicates correct understanding? "The meconium is hard and pale brown." "The meconium is sticky and greenish black." "The meconium is soft and pale yellow." "The meconium is loose and golden yellow."
"The meconium is sticky and greenish black." Meconium is sticky and greenish black. Meconium is not loose, golden yellow, hard, pale brown, or pale yellow. Examples of newborn stools. A. Meconium. B. Transitional stool. C. Fecal stool.
A 4-week-old formula-fed newborn had a birth weight of 7 lb (3.17 kg). Which newborn weight should the nurse anticipate? 7 lb, 7 oz (3.37 kg) 8 lb, 14 oz (4.02 kg) 8 lb, 7 oz (3.82 kg) 7 lb, 14 oz (3.57 kg)
7 lb, 14 oz (3.57 kg) It is normal for the newborn to lose weight after birth, but the newborn is expected to continue gaining weight after 2 weeks of age at the rate of 1 oz (28.3 g) per day. The newborn is expected to weigh approximately 7 lb, 14 oz (3.57 kg) after 4 weeks, based on an expected gain of 1 oz (28.3 g) per day. The nurse would not expect the infant to gain more than this amount during this time frame.
The nurse notes that 1 minute after birth, a newborn has a heart rate of 140 beats/min, prompt crying with stimulation occurs, blue extremities, a lusty cry, and is able to maintain minimal flexion with sluggish movement. Which Apgar score should the nurse assign the newborn? 8 7 9 10
8 The Apgar scoring system is used to evaluate the physical condition of the newborn at birth. The newborn is rated 1 minute after birth and again at 5 minutes and receives a total score (Apgar score) ranging from 0 to 10 based on the following assessments: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. The score for each category ranges from 0-2. Two points each are assigned for heart rate, respiratory effort, and reflex irritability. One point each is assigned for color and muscle tone, for a total score of 8.
After reviewing the maternal prenatal record, the nurse performs an assessment on a newborn. For which maternal factor should the nurse perform additional assessment on the newborn? (Select all that apply.) A. Diabetes B. Long, difficult labor C. Maternal narcotic use D. Maternal history of infection E. Mode of delivery
A B C D Rationale: Diabetes is associated with an increased risk of hypoglycemia. A lengthy difficult labor and a maternal history of infection place the newborn at risk of infection and sepsis. Maternal use of narcotics places the newborn at risk of neuromuscular abnormalities as well as other complications. The mode of delivery does not generally place the infant at risk for complications or warrant additional measures of assessment.
A newborn has a "belly band" that has been placed around the abdomen by the parents. Which should correctly explain this practice? A. Protect against injury. B. Provide comfort. C. Identify the baby. D. Ward off evil spirits.
A Rationale: A "belly band" is associated with the cultural belief of protecting the newborn against injury. The belly band is not a means of providing comfort, identifying the baby, or warding off evil spirits.
The nurse is performing an assessment on a newborn. Which assessment finding should the nurse identify as normal? Panting Grunting Acrocyanosis Central cyanosis
Acrocyanosis Acrocyanosis is a normal finding in a newborn. It occurs due to vasomotor instability and can last up 24-48 hours after birth. Grunting may indicate respiratory distress and may require close monitoring by the nurse but not necessarily immediate intervention. Central cyanosis is a sign of severe respiratory distress and would require immediate intervention by the nurse.
The nurse is performing an assessment on a newborn 12 hours after birth. Which assessment finding should indicate that the newborn may be experiencing a problem with the cardiopulmonary adaptation to extrauterine life? A. Hypotension B. Grunting C. Eupnea D. Hyperglycemia
B Rationale: Grunting indicates the newborn may be experiencing hypoxia. Eupnea, or normal breathing, is a normal finding. Hypotension, while an abnormal finding, is not indicative of a problem with cardiopulmonary adaptation to extrauterine life. Hyperglycemia, which can occur during the initial newborn period, is not an indicator of a problem with cardiopulmonary adaptation.
The nurse is teaching new parents about their newborn's sensory capacities. Which topic should the nurse identify as least appropriate at this time? A. Olfactory B. Habituation C. Auditory D. Tactile
B Rationale: Habituation is the newborn's ability to process and respond to complex stimulation. Tactile, auditory, and olfactory are sensory capacities.
The nurse notes that a 2-hour-old neonate has plantar creases over the entire foot. Which gestational age should the nurse determine for this newborn? A. Preterm B. Full term C. 32 weeks D. 36 weeks
B Rationale: Plantar creases covering the entire foot are a characteristic of a full-term neonate. The plantar creases are not used to determine the gestational age of extremely preterm infants. One to two creases appear at approximately 32 weeks of gestation. By 36 weeks of gestation, creases cover the anterior two-thirds of the foot.
The nurse is assigned to care for a 2-hour-old newborn. Which action should the nurse take when assessing this client? A. Count respirations for 30 seconds. B. Count apical heart rate for a full minute. C. Stimulate to assess for alertness. D. Measure blood pressure first.
B Rationale: The apical heart rate should be assessed first, for a full minute. A blood pressure is not routinely measured during the assessment of a newborn unless there is a suspected cardiac anomaly, or the infant is in distress or premature. Respirations should be counted for a full minute. The newborn should first be assessed in the resting position, and vital signs should be taken while the newborn is at rest.
The nurse is preparing for the birth of a newborn with intrauterine growth restriction (IUGR). Which testing should the nurse anticipate performing immediately after delivery? A. CBC B. Glucose C. Blood cultures D. Bilirubin
B Rationale: The newborn with IUGR is at risk for hypoglycemia. A complete blood count (CBC) and blood cultures are not necessary unless an infection is suspected. Bilirubin level is not a priority immediately after birth.
A neonate is small for gestational age (SGA). Which assessment should the nurse identify as least appropriate at this time? A. Hypoglycemia B. Hypokalemia C. Aspiration D. Hypothermia
B Rationale: A newborn that is SGA is not at risk for hypokalemia. Hypokalemia occurs secondary to other pathologic conditions. Newborns who are small for gestational age (SGA) are at risk for certain complications such as hypoxia, aspiration, hypothermia, hypoglycemia, polycythemia, and ongoing growth and development problems.
A neonate who had Apgar scores of 5 and 8 has central cyanosis and a respiratory rate of 0 after 10 minutes. Which action should the nurse take? A. Assess vital signs. B. Repeat the Apgar test again in 5 minutes. C. Begin neonatal resuscitation. D. Administer a glucose feeding.
C Rationale: Resuscitation is required for central cyanosis and absent respirations. Vital signs can be assessed when the neonate is stabilized. Feeding a newborn is contraindicated in respiratory distress. The Apgar score is not a priority action and is not used to determine the need for resuscitation.
The nurse is caring for a newborn immediately following delivery. For which reason should the nurse implement actions to prevent hypothermia? A. Radiation B. Conduction C. Evaporation D. Convection
C Rationale: Evaporation occurs when moisture on the newborn's skin is converted to vapor. Newborns are prone to this method of heat loss in the delivery room since they are coming from a warm, moist environment into a cool, drier environment. Radiation is the transfer of the newborn's body heat to cooler objects that are not in direct contact with the skin. Convection is the transfer of heat to the air surrounding the newborn. Conduction is heat loss that occurs when there is direct contact with cooler objects.
A newborn has an increased apical heart rate, respiratory rate, and mucus secretions that are causing regurgitation. Which period of reactivity should the nurse recognize this client is demonstrating? A. Third B. First C. Second D. Fourth
C Rationale: The findings most often occur during the second period of reactivity. The second period of reactivity lasts approximately 4 hours. The first period of reactivity occurs immediately after birth and lasts approximately 30 minutes. The newborn is alert and active and may be hungry. There is no third or fourth period of reactivity.
The nurse is discussing the initial respiratory effort of a newborn with colleagues. Which best describes the primary purpose of the mechanical action of chest recoil? Prevent aspiration of amniotic fluid Clear accumulated fluid in the airway Increase the rate at which fluid is absorbed Prevent atelectasis
Clear accumulated fluid in the airway The primary purpose of the mechanical action of chest recoil results in clearing of accumulated fluid in the airway. The primary purpose of chest recoil is not to increase the rate of fluid absorption, prevent aspiration of amniotic fluid, or prevent atelectasis.
The nurse is suctioning a newborn that has excessive oral and nasal secretions. Which complication of mechanical suctioning should the nurse monitor in the newborn? A. Decreased level of consciousness B. Increased temperature C. Increased blood pressure D. Decreased heart rate
D Rationale: Excessive mechanical suctioning can cause a vasovagal response in the newborn, resulting in a decreased heart rate. Mechanical suctioning is not related to the newborn's temperature. Blood pressure elevation in the newborn is not considered a complication of mechanical suctioning. The infant's level of consciousness should not be affected by mechanical suctioning of the oral and nasal cavities.
The parents of a 2-day-old neonate are concerned about a 2% weight loss since birth. Which response should the nurse make? A. "I will have the healthcare provider speak to you about this." B. "This is okay. We expect babies to lose about half of their weight in the first few days of life." C. "This is worrying because we expect the newborn to gain 1 pound per day." D. "This is an expected finding. Most infants will regain this weight within 2 weeks after birth."
D Rationale: It is normal for newborns to lose body weight during the first 3-4 days of life. On average, infants can lose up to 7-10% of their body weight due to fluid shifts. The nurse can reassure the parents and inform the healthcare provider of their concern. Infants should start to regain weight within the first 2 weeks of life. A newborn is not expected to gain 1 lb (0.45 kg) per day or experience a weight loss of half the birth weight.
The nurse is evaluating the newborn's rooting reflex. With which part of the newborn assessment should the nurse associate this reflex? A. Physical maturity assessment B. Vital signs C. Apgar score D. Neuromuscular
D Rationale: The rooting reflex is part of a neuromuscular assessment. Neuromuscular characteristics are used to evaluate the physiological maturity of the newborn. Vital signs are used to evaluate the physiological stability of the newborn. The Apgar score is used to evaluate the physical condition of the newborn at 1 and 5 minutes after birth. Physical characteristics are used in the evaluation of the physical maturity of the newborn.
The nurse is assisting the healthcare provider with the circumcision of a newborn. Which intervention should the nurse implement to prevent a postprocedural infection? A. Instructing the parents about the signs and symptoms of infection B. Administering a prophylactic antibiotic C. Wrapping the circumcised area with Vaseline gauze D. Providing sterile supplies during the procedure
D Rationale: Using sterile supplies during the procedure reduces the risk of an infection afterwards. Prophylactic antibiotic administration is not standard procedure prior to a circumcision. Wrapping the circumcised area with Vaseline gauze does not decrease the likelihood of postprocedural infection. Instructing the parents about the signs and symptoms of infection will help identify a potential infection.
The nurse is teaching a new nurse about the nutritional intake and elimination for a neonate after birth. Which statement should the nurse include in the information? A. "Excessive handling will help stimulate the newborn to eat." B. "A weight loss of 15% is normal in the first week of life." C. "The first voiding and stooling should occur within 12 hours." D. "Early feedings promote gastric emptying and peristalsis."
D Rationale: Early feedings promote gastric emptying and increase peristalsis, thereby decreasing the potential for hyperbilirubinemia by decreasing the amount of time that fecal material is in contact with the enzyme betaglucuronidase in the small intestine. A weight loss of 10% is normal in the first week of life. Excessive handling can cause an increase in the newborn's metabolic rate and caloric use and also cause fatigue. The newborn?s first voiding or stooling should occur within 12-24 hours after birth.
Which intervention should the nurse implement to prevent newborn hypothermia? A. Spreading a room-temperature blanket over the newborn B. Placing a shirt on the newborn under a radiant warmer C. Conducting the initial bath in an open crib D. Placing the infant skin to skin with the mother
D Rationale: Placing the infant skin to skin with the mother helps prevent hypothermia. The initial bath should be performed under a radiant warmer and the blankets covering the newborn after birth should be preheated to prevent hypothermia. A shirt should not be placed on the infant under a radiant warmer to prevent hyperthermia.
The nurse is reviewing the prenatal record of a client with a newborn that is large for gestational age (LGA). Which maternal condition should the nurse identify that may have contributed to the newborn's status? A. Multiple gestations B. Maternal hypertension C. Maternal substance abuse D. Gestational diabetes
D Rationale: The maternal condition that is associated with an LGA newborn is gestational diabetes. Multiple gestation, maternal hypertension, and substance abuse are associated with intrauterine growth restriction.
The nurse is assessing a sleeping newborn who is 1 hour old. Which data should alert the nurse to notify the healthcare provider? A. Brief periods of apnea lasting less than 5 seconds B. Temperature 97.9degreesF (36.6degreesC) C. Heart rate 122 beats/min D. Respirations 78 breaths/min
D Rationale: The normal newborn respiratory rate is 30-60 breaths/min. A temperature of 97.9°F (36.6°C) is a normal finding. A normal temperature range is 97.7°F to 98.6°F (36.5°C to 37.0°C). A normal heart rate range is 110-160 beats/min. Brief periods of apnea lasting less than 5 seconds are a normal finding.
The nurse has received report on a newborn who was delivered vaginally at 3:30 p.m. At which time should the nurse perform the newborn assessment? A. 4:00 p.m. B. 6:30 p.m. C. 4:30 p.m. D. 5:30 p.m.
D Rationale: The nurse will perform the newborn assessment by 5:30 p.m. For an uncomplicated delivery, the assessment should be performed within 2 hours of birth. The assessment can be performed at 4:00 or 4:30 p.m., but during the first few hours, bonding and breastfeeding should be promoted with minimal interruption.
The hemoglobin and hematocrit levels of a 10-day-old newborn reflects anemia. Which factor should the nurse understand contributes to the decreased hemoglobin level of the newborn? Decrease in oral fluids in the newborn Increase in plasma volume Decrease in the number of red blood cells Decrease in red blood cell mass
Decrease in red blood cell mass The primary contributing factor to the physiological anemia of infancy is a decrease in the red blood cell mass. An additional factor that influences the degree of physiological anemia is the nutritional status of the newborn. Supplies of vitamin E, folic acid, and iron may be inadequate given the amount of growth in the later part of the first year of life. The decrease in the lifespan of the red blood cells and lifespan of plasma contribute to the physiological anemia of the newborn. A decrease in oral fluids increases the hematocrit level.
The nurse is caring for a newborn with polycythemia. Which health problem should the nurse realize the mother is most likely being treated for? Systemic lupus erythematosus Hypertension Diabetes Hyperthyroidism
Diabetes Polycythemia in the newborn is associated with maternal diabetes. Polycythemia in the newborn is not associated with maternal hypertension, hyperthyroidism, or systemic lupus erythematosus.
The nurse is caring for a newborn who has just been born and placed on the mother's chest. Which action should the nurse take next? Assessing the heart rate Initiating breastfeeding Obtaining the 1-minute Apgar Drying the baby
Drying the baby The newborn should be dried and removal of wet blankets is necessary to prevent heat loss. The assessment of the heart rate, Apgar score, and initiation of breastfeeding can be initiated after the neonate has been dried.
A patient in labor admits to illegal substance abuse throughout the pregnancy. Which neonatal assessment finding should the nurse anticipate after delivery of the newborn? Polycythemia Hypoglycemia Intrauterine growth restriction Lethargy
Intrauterine growth restriction A newborn habitually exposed to an illegal substance is at risk for intrauterine growth restriction (IUGR). Lethargy, polycythemia, and hypoglycemia are not associated with illegal substance abuse.
During labor, a patient's amniotic membranes rupture and the fluid appears green in color. Which collaborative intervention should the nurse anticipate? Maternal antibiotic administration Emergency cesarean birth Surfactant replacement Neonatal intubation
Neonatal intubation Green amniotic fluid indicates that the neonate has passed meconium into the amniotic fluid. Meconium is passed in utero secondary to stress or hypoxia. This fluid may be aspirated into the tracheobronchial tree in utero or during the first few breaths taken by the newborn. Meconium causes chemical irritation and also forms small balls that become lodged in terminal airways, allowing some air to enter the alveoli but not allowing air to escape. The neonate may need to be intubated after birth, so additional suctioning of the airway can be performed to prevent aspiration. A maternal antibiotic, surfactant replacement, and a cesarean birth are not necessary in the treatment of meconium-stained fluid.
The nurse is teaching a patient who is breastfeeding about the color of stools that can be anticipated for the newborn after the meconium stool. How should the nurse describe the stool? Thick and green Thin and brown Continue to be thick and tarry Pale yellow
Pale yellow After the meconium stool, the color of stool for a baby being breastfed is pale yellow. Thin brown stools, thick tarry stools, and thick green stools are not a normal finding for baby being breastfed.
The nurse has suctioned the airway of a term neonate immediately after a spontaneous vaginal delivery. Which action should the nurse take next? Instilling erythromycin in the baby's eyes Placing identification bracelets on the neonate Obtaining the neonate's weight Placing the neonate skin-to-skin with the mother
Placing the neonate skin-to-skin with the mother After suctioning the infant, the neonate should be placed skin-to-skin with the mother to prevent cold stress and promote bonding. Instilling erythromycin in the neonate's eyes, obtaining a weight, and placing identification bracelets on the neonate are not priority actions.
The nurse is assessing a newborn. Which data should the nurse use to determine the newborn's gestational age? Plantar creases on the sole Apgar score Size of the anterior fontanel Presence of milia
Plantar creases on the sole The plantar creases on the sole are used to determine gestational age. Other indicators for gestational age include skin texture, lanugo, breast tissue, eyes and ears, and genitalia. The Apgar score, size of the anterior fontanel, and the presence of milia are not used to determine gestational age.
The nurse is caring for a large for gestational age (LGA) newborn who was born to a mother with type I diabetes. Which condition should the nurse monitor in the newborn? Hypobilirubinemia Polycythemia Bradypnea Hypertension
Polycythemia Polycythemia in the newborn is associated with maternal diabetes. Polycythemia is a result of increased blood viscosity in the newborn. Bradypnea, hypobilirubinemia, and hypertension are not associated with maternal diabetes.
The nurse is performing a general physical assessment on a newborn. Which finding should indicate the need to assess the blood glucose level? Excessive sleeping Hyperreflexia Tremors Hyperthermia
Tremors Tremors are a sign of hypoglycemia. Hypoglycemia is further characterized by temperature instability, jitteriness, and poor feeding. Hyperthermia, hyperreflexia, and sleeping are not findings associated with hypoglycemia.
The nurse is teaching a postpartum patient on newborn care. Which information should the nurse include about the normal voiding pattern of a newborn? Void at least 5 times per day after the first few days Have 2-4 wet diapers per day by the end of the first day Have 4-6 wet diapers per day by the end of the first week Have at least 10 wet diapers per day by the end of the first week
Void at least 5 times per day after the first few days The newborn should void at least 5 times per day after the first few days. During the first 2 days after birth, the newborn voids 2-6 times daily, with a urine output of 15 mL/kg per day.