Newborn AQ

The nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. Which part of the foot is the best site to use for the puncture? Big toe Foot pad Inner sole Outer heel

Outer heel (The outer heel is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.)

The nurse is caring for a newborn with a caput succedaneum. What is the priority nursing action? Supporting the parents Recording neurologic signs Applying a hard protective cap on the head Applying ice packs to the hematoma

Supporting the parents (Parents need support and reassurance that their newborn is not permanently damaged. Caput succedaneum does not cause impaired neurologic function. No special protection of the head is required; routine safety measures are adequate.)

A mother is concerned that her newborn will be exposed to communicable diseases after she is discharged. While teaching the mother ways to decrease the risk of infection, what type of immunity should the nurse explain was transferred to her baby through the placenta? Active natural Passive natural Active artificial Passive artificial

Passive natural (Passive natural immunity is developed from an antigen-antibody response in the mother that is transmitted to the fetus. Active natural immunity is acquired by an individual in response to a disease or an infection. Active artificial immunity is acquired by an individual in response to small amounts of antigenic material (e.g., vaccination). Passive artificial immunity is conferred by the injection of antibodies prepared in another host.)

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Record your answer using a whole number.

8 (The Apgar score is 8. A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet.)

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? "It will keep your baby from going blind." "This ointment will protect your baby from bright lights." "There is a law that newborns must be given this medicine." "This antibiotic helps keep babies from contracting eye infections."

"This antibiotic helps keep babies from contracting eye infections." (Erythromycin ophthalmic ointment is used to treat gonorrhea and Chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.)

The nurse in the birthing room is assessing a newborn. Which characteristic would be assigned an Apgar value of 2? A strong cry A heart rate of 90 beats/min Slight flexion of legs and arms Pink body and blue extremities

A strong cry (A strong cry indicates effective respiratory function and is assigned a value of 2. If flexion of the arms and legs is slight and movement is diminished, a value of 1 is assigned. A value of 1 is assigned when the body is pink and the extremities are blue. The heart rate should be more than 100 beats/min; therefore a pulse of 90 beats/min is assigned a value of 1.)

A newborn boy is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do? Apply the diaper loosely for several days Give a crushed baby aspirin if there is irritability Check for bleeding every 2 hours during the first day home Call the practitioner if there is whitish exudate around the glans

Apply the diaper loosely for several days (The diaper is applied loosely to prevent pressure on the circumcised area because the glans remains tender for 2 to 3 days. Aspirin may prolong clotting and is contraindicated in children because of its relationship to Reye syndrome. Acetaminophen and comfort measures may be prescribed. The caregiver should check for bleeding every hour for the first 12 hours after the circumcision. Whitish exudate around the glans is expected and does not indicate an infectious process.)

Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0° F (36.7° C) and 97.4° F (36.3° C) would be considered critical? Respiratory rate of 60 breaths/min White blood count greater than 15,000 mm3 Serum calcium level of 8 mg/dL (2 mmol/L) Blood glucose level of 36 mg/dL (3.8 mmol/L)

Blood glucose level of 36 mg/dL (3.8 mmol/L) (Instability of the newborn's temperature is an indication of hypoglycemia. A glucose level below 40 mg/dL (1.7 mmol/L) does not provide enough energy to maintain the body temperature at a normal level. A serum calcium level of 8 mg/dL (2 mmol/L), respiratory rate of 60 breaths/min, and a white blood cell count greater than 15,000 mm3 are all normal findings and do not affect body temperature.)

The nurse is assessing a term newborn. Which sign should the nurse report to the pediatric primary healthcare provider? Temperature of 97.7° F (36.5° C) Pale-pink to rust-colored stain in the diaper Heart rate that decreases to 115 beats/min Breathing pattern with recurrent sternal retractions

Breathing pattern with recurrent sternal retractions (A breathing pattern with recurrent sternal retractions is indicative of respiratory distress; the expected pattern is abdominal with synchronous chest movement. A temperature of 97.7° F (36.5° C) is within the expected range of 97.6° F (36.4° C) to 99° F (37.2° C) for a newborn. Pale-pink to rust-colored staining in the diaper is caused by uric acid crystals from the immature kidneys; it is a common occurrence. A decrease in heart rate to 115 beats/min is within the expected range of 110 to 160 beats/min for a newborn.)

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of what characteristic of the scalp edema in caput succedaneum? Becomes ecchymotic Crosses the suture line Increases after several hours Is tender in the surrounding area

Crosses the suture line (Scalp edema that crosses the suture line is the clinical finding that differentiates between these two conditions. With caput succedaneum the swelling crosses the suture line, whereas in cephalhematoma it does not. Bruising may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will need to be observed for signs of increased intracranial pressure. Pain is not associated with either condition.)

What action should the nurse take to assist parents with bonding immediately after birth? Assess for typical parenting techniques Demonstrate desired behaviors to the parents Delay applying the antibiotic to the newborn's eyes Postpone footprinting the newborn until later in the day

Delay applying the antibiotic to the newborn's eyes (The parents need an opportunity for close eye-to-eye contact during the first hour after birth. Prophylactic eye medications may irritate the newborn's eyes, preventing them from opening. Assessment is appropriate but will not facilitate parent-newborn bonding; favorable conditions for bonding should be provided before assessment. The nurse should assess, not demonstrate, behavior at this time. Footprinting should be done immediately to ensure proper identification of the newborn.)

The nurse is caring for a neonate who is undergoing phototherapy. What specific care should the nurse plan for this infant? Applying mineral oil to the skin to prevent excoriation Covering the infant's head with a cap to minimize heat loss Regulating radiant heat to maintain optimum skin temperature Discontinuing therapy during feeding to meet the infant's emotional needs

Discontinuing therapy during feeding to meet the infant's emotional needs (Discontinuing therapy during feedings is necessary to ensure psychosocial contact. Mineral oil may block light rays from acting on bilirubin deposits; cleansing after each voiding and defecation will prevent skin excoriation. All parts of the body may contain bilirubin deposits and should be exposed to the light. Radiant heaters are not used; a fluorescent light source is used.)

A client is rooming in with her newborn. The nurse observes the infant lying quietly in the bassinet with the eyes open wide. What action should the nurse take in response to the infant's behavior? Brightening the lights in the room Encouraging the mother to talk to her baby Wrapping and then turning the infant to the side Beginning physical and behavioral assessments

Encouraging the mother to talk to her baby (A quiet, alert state is an optimal time for infant stimulation. Bright lights are disturbing to newborns and may impede mother-infant interaction. Wrapping and then turning the infant to the side is done for the sleeping infant. Physical and behavioral assessments are not the priorities; they may be delayed.)

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take at this time? Giving the infant to the mother Having the visitor step outside the room Verifying the infant's and mother's identification bands Asking the visitor whether the coughing and sneezing are caused by a cold

Having the visitor step outside the room (Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother's and newborn's identification bands have been verified. Verifying the infant's and the mother's identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present.)

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge? To space feedings at every 3 hours How to assess the fontanels for tenseness How to monitor their child for signs of jaundice To record the number of wet diapers during the first 24 hours

How to monitor their child for signs of jaundice (Bilirubin is a yellow pigment derived from the hemoglobin released with the breakdown of red blood cells as the hematoma resolves. Signs of jaundice should be reported. Spacing feedings every 3 hours, assessing the fontanels, and recording the number of wet diapers in the first 24 hours are not specific for a healthy neonate with a cephalhematoma.)

A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem should the nurse anticipate when planning care for this infant? Anemia Hypoglycemia Protein deficiency Calcium deficiency

Hypoglycemia (Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary healthcare provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.)

When calculating the Apgar score for a newborn, what does the nurse assess in addition to the heart rate? Muscle tone Amount of mucous Degree of head lag Depth of respirations

Muscle tone (The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not the depth, is assessed for an Apgar score. Amount of mucus, degree of head lag, and depth of respirations are not tested for an Apgar score.)

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to what? Early rooming-in Taking-in behaviors Taking-hold behaviors Parent-child attachment

Parent-child attachment (There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychologic behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychologic behavior described by Rubin that occurs after the third postpartum day.)

A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs? Encouraging the father's participation in a parenting class Providing time for the father to be alone with and get to know the baby Offering the father a demonstration on newborn diapering, feeding, and bathing Allowing time for the father to ask questions after viewing a film about a new baby

Providing time for the father to be alone with and get to know the baby (Time alone provides the opportunity for paternal-infant attachment/bonding. Touching the infant may reduce some of the father's anxiety. Although helpful, a parenting class does not meet the need for paternal-infant attachment/bonding. A demonstration on newborn diapering, feeding, and bathing does not acknowledge the father's anxiety; also, he may not be ready to absorb this information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach to the father's emotional needs and does not address the father's concerns.)

Which intervention will be delayed until the newborn is 36 to 48 hours old? Vitamin K injection Test for blood glucose level Screening for phenylketonuria Test for necrotizing enterocolitis

Screening for phenylketonuria (In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test.)

A newborn's discharge from the hospital is being delayed because of a rising reticulocyte count. The infant's mother, who is being discharged, asks the nurse why her baby must stay. The nurse's response is based on the understanding that the infant must be observed for what? Bacterial infection Significant jaundice Bleeding tendencies Adequate oxygenation

Significant jaundice (A rising reticulocyte count indicates accelerated erythropoietic activity that may reflect increased red blood cell (RBC) destruction; increased RBC destruction increases the bilirubin level, causing jaundice. With an infection the sedimentation rate or white blood cell (WBC) count, not the reticulocyte count, is increased. Although the reticulocyte count may be increased with chronic blood loss, there are no data to indicate that the infant is bleeding. This test does not reflect respiratory function.)

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? The ribcage is not compressed and released during birth. The sudden temperature change at birth causes aspiration. There is usually oxygen deprivation after a cesarean birth. There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed and released during birth. (The release following compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.)

Which newborn assessment finding will probably necessitate prolonged follow-up care? Apgar score of 5 Weight of 3500 g Umbilical cord with two blood vessels Blood glucose level of 50 mg/dL (1.7 to 3.3 mmol/L)

Umbilical cord with two blood vessels (The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. The interval at which the Apgar score was obtained was not provided. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL (1.7 to 3.3 mmol/L))

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider? Weight of 6 lb 4 oz (2835 g) Hemoglobin of 16.2 g/dL (162 mmol/L) Three wet diapers over the last 12 hours Total serum bilirubin of 10 mg/dL (171 µmol/L)

Weight of 6 lb 4 oz (2835 g) (A loss of 12 oz (340 g) since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL (162 mmol/L), total serum bilirubin of 10 mg/dL (171 µmol/L), and three wet diapers over the last 12 hours are all normal and expected findings.)

A newborn is admitted to the nursery. The newborn weighs 10 lb, 2 oz (4592 g), which is 2 lb (907 g) more than the birthweight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight? Document the findings Delay starting oral feedings Perform serial glucose readings Place the newborn in a heated crib

Perform serial glucose readings (A large newborn may be the result of gestational diabetes; it is necessary to check the neonate for hypoglycemia, because maternal glucose is no longer available. The nurse should do more than document the findings; the primary healthcare provider should be notified after the serial glucose readings are taken. Placing the infant in a heated crib is indicated if the temperature is low and the newborn needs additional warmth. The infant may be hypoglycemic and require the glucose in an oral feeding immediately.)

What does an Apgar score recorded 5 minutes after birth assist the nurse in evaluating when caring for the newborn? Gestational age of the newborn Effectiveness of the birthing process Possibility of respiratory distress syndrome Adequacy of the transition to extrauterine life

Adequacy of the transition to extrauterine life (The score at 5 minutes indicates the adequacy of the cardiac and respiratory systems' response to the environment. The Dubowitz score is related to gestational age. The score represents the neonate's response to the environment and is not related to the actual process of labor and birth. The Apgar score is not a diagnostic tool for respiratory distress syndrome.)

A primipara has just given birth at 37 weeks' gestation. What should the nurse do to assist the attachment process between the mother and her newborn? Encourage continuous rooming-in Assign one nurse to care for both of them Allow extra visiting privileges in the nursery Teach the client how to breast-feed the baby

Encourage continuous rooming-in (Rooming-in provides time for the mother and newborn to be together; the mother can become acquainted with the infant more quickly. It is possible that the client does not want to breast-feed; attachment can be furthered by means of a variety of methods. Assigning one nurse to care for both client and infant will not promote bonding and attachment. Although visiting in the nursery is unlimited for the parents, rooming-in is preferable.)

A nurse teaches a couple about care of their newborn, who has been circumcised. The nurse concludes that the teaching is effective when the father says what? "We shouldn't expect fussy behavior." "We should leave the baby undiapered." "We should apply petrolatum gauze to the penis." "We should notify the clinic if we see a yellow discharge."

"We should apply petrolatum gauze to the penis." (Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Yellow exudate is expected; it is not a sign of an infectious process.)

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant? Less than 40% More than 75% Between 45% and 65% Between 65% and 75%

Between 45% and 65% (The expected hematocrit level for a healthy newborn is between 45% and 65%. Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.)