Newborn Adaptation/Nursing Management

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"His urinary meatus in located on the under surface of the glans."

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?

"I will give him vitamin D supplements daily for the first 2 months of life."

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement, by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

The parents of a newborn are concerned that the different procedures are causing pain for their newborn. Which action should the nurse prioritize to address the parent's concerns?

Advocate and use effective treatment methods that cause no pain or less pain.

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

Chlamydia Gonorrhea

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly.

The nursery head nurse is conducting an in-service on prevention of hypoglycemia to her staff. What information would she share with this group? Select all that apply.

Encourage breast-feeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein's pearls.

The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant?

Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

Look at the woman's hospital identification badge.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the eyes from vaginal bacteria

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met?

Promote early breastfeeding for the infants.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty.

A woman has just given birth vaginally to a newborn. Which action will the nurse do first?

Suction the mouth and nose.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation.

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

lethargy and hypotonia

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye

A nurse is preparing to conduct a neurological physical assessment of a neonate, including an evaluation of the major congenital reflexes. Which reflexes would the nurse assess? Select all that apply.

gag Babinski Moro Galant

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply.

lanugo genitals

All the options are signs of respiratory distress in the newborn except:

respiratory rate >50 breaths/minute.