Newborn Prep u
The mother of a 1-day-old newborn calls the nurse alarmed and asks the nurse to hurry to her room because there is something wrong with her newborn. The nurse arrives to find the newborn lying on the side, awake and crying with one side of the body a dark red color and the other side of the body pale. What would the nurse tell this mother? "Your newborn needs to go back to the nursery so the health care provider can examine the newborn for a possible cardiac problem." "I need to give your newborn some oxygen to help raise the blood oxygen level." "This is a harlequin sign and is a normal finding in newborns. It usually occurs when the newborn is crying or when lying on the side." "I have never seen anything like this but your newborn is crying and active, so I am sure your newborn is OK."
"This is a harlequin sign and is a normal finding in newborns. It usually occurs when the newborn is crying or when lying on the side."
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 apply a moisture barrier cream with every diaper change to prevent diaper rash." "We should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "It is best practice to change the diaper every 2 to 4 hours, even during the night."
"We will fold down the front of her diaper under the umbilical cord until it falls off."
New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn on the mobile that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."
"We'll hold off on feeding him for a while because he might be too full."
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? A birth weight between 2200 and 3000 g is considered small for gestational age. A length between 48 and 50 cm plots out at the 95th percentile for length. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. Normal birth length is usually 52 cm or above for a full-term newborn.
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? Ask the woman to bring the infant back when the doctor finishes the examination. Call the nursery to confirm the doctor does indeed need this infant at this time. Ask to see the woman' hospital identification badge. Ask how long the infant will be gone since her next feeding is in 30 minutes.
Ask to see the woman' hospital identification badge.
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? Administer an oral dose of vitamin K to the newborn. Assume that the parents refused this medication for their infant. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Check blood glucose. Place child in a radiant warmer. Assess for pain source. Assess the baby's temperature.
Check blood glucose.
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation
Convection
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation
Convection
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? Epstein pearls milia stork bites Mongolian spots
Epstein pearls
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Administer the medication. Determine the newborn's weight. Identify the newborn. Assess the newborn for bleeding.
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. Clean the cord with soap and water, as oozing of blood is a common finding. Remove the clamp and replace with another one just above the old one. Notify the doctor to come suture the site of the bleeding.
Inspect the clamp to insure that it is tightly closed and applied correctly.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? This is an abnormal finding and needs to be reported immediately. If the fontanel (fontanelle) feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).
The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? It expands the lungs with breaths. It keeps alveoli from collapsing with breaths. It removes fluid from the lungs. It allows oxygen to move in the lungs.
It keeps alveoli from collapsing with breaths.
The nurse is conducting a prenatal class explaining the various activities that 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 umbilical cord Prevent infection of the eyes from vaginal bacteria Protect tear ducts from vaginal bacteria Protect the urethra from fecal material
Prevent infection of the eyes from vaginal bacteria
A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Provide warm water to drink. Provide oxygen supplementation. Massage the newborn's back. Ensure the newborn's warmth. Observe respiratory status frequently.
Provide oxygen supplementation. . Ensure the newborn's warmth. Observe respiratory status frequently.
A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns? Respiratory rate of 40 breaths/min Temperature instability Heart rate of 152 beats/min Erythema toxicum
Temperature instability
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? Suction the mouth and then the nose with a suction catheter. Place the newborn on its stomach with the head down and gently pat its back. Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose.
Using a bulb syringe, suction the mouth then the nose.
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Warmer bed Glucose water Suction equipment Identification bands Ophthalmoscope
Warmer bed Suction equipment Identification bands
The experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns? Wearing artificial nails while caring for multiple newborns. Using hand sanitizer when the hands are not visibly soiled. Wearing gloves while swaddling an unbathed newborn. Washing the hands for 3 minutes at the start of the shift.
Wearing artificial nails while caring for multiple newborns.
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? Apgar score blood sugar heart rate temperature
blood sugar
The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? spinal column movement shoulder movement clavicles for dislocation hip for dislocation
hip for dislocation
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? increased appetite increase in the body temperature lethargy and hypotonia hyperglycemia
lethargy and hypotonia
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? thick skin with deep lying blood vessels enhanced shivering ability expanded stores of glucose and glycogen limited voluntary muscle activity
limited voluntary muscle activity
A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding 24 hours after admission to the nursery on admission to the nursery 4 hours after admission to the nursery
on admission to the nursery
According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and he/she has minimal activity or body movement? drowsy quiet alert active alert active attentive
quiet alert
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue sweating and peripheral vasoconstriction radiation, convection, and conduction
radiation, convection, and conduction
When assessing the newborn's umbilical cord, what should the nurse expect to find? two smaller arteries and one larger vein two smaller veins and one larger artery one smaller vein and two larger arteries one smaller artery and two larger veins
two smaller arteries and one larger vein
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that: this is a normal finding. this is most likely a symptom of impending diarrhea. her child may be developing an allergy to breast milk. her child will need to be isolated until the stool can be cultured.
this is a normal finding.
What is the primary goal of nursing care immediately after birth? to obtain weight and length to give the mother a chance to breastfeed to maintain the safety of the neonate from intrauterine to extrauterine life to ascertain whether the neonate needs lab tests
to maintain the safety of the neonate from intrauterine to extrauterine life
When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? "I can use talc powders to prevent diaper rash." " I will change my baby's diapers frequently." "I will give sponge baths until the umbilical cord falls off." "It is not necessary to give my baby a bath daily."
"I can use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.
A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."
"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? "Change the newborn's diaper every four hours while awake." "Place the newborn on the back to sleep and stomach to play." "Newborns can sleep on a couch to allow constant visual monitoring." "You need to give your newborn a bath everyday."
"Place the newborn on the back to sleep and stomach to play."
What is the expected range for respirations in a newborn? 10 to 30 breaths per minute 20 to 40 breaths per minute 30 to 60 breaths per minute 40 to 80 breaths per minute
30 to 60 breaths per minute
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? Reticulocyte count is 6%. Hematocrit is 38. Skin looks less jaundiced. Bilirubin level went from 15 to 11.
Bilirubin level went from 15 to 11.
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? Heart Rate Respiratory Rate Blood Pressure Temperature
Blood Pressure
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? Inform the mother of the results of the hearing test completed on the newborn. Compare the identification bracelets prior to leaving the newborn with the mother. Explain the procedure completed on the newborn to the mother. Determine if it is time for the mother to breastfeed the newborn and assist as needed.
Compare the identification bracelets prior to leaving the newborn with the mother.
The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action? Infant A - 52 mg/dl Infant B - 56 mg/dl Infant C - 48 mg/dl Infant D - 60 mg/dl
Infant C - 48 mg/dl Blood glucose levels between 50 and 60 mg/dl during the first 24 hours of life are considered normal.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? fencing Moro tonic neck rooting
Moro
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? Soak the penis daily in warm water. Cover the glans generously with petroleum jelly. Cleanse the glans daily with alcohol. Notify the primary care provider if it appears red and sore.
Notify the primary care provider if it appears red and sore.
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? Check the client's blood sugar by a venous blood draw. Feed the newborn some formula immediately. Start an IV to provide intravenous glucose. Perform a heel stick to obtain a blood sample for testing for glucose level.
Perform a heel stick to obtain a blood sample for testing for glucose level.
Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply. Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Labia minora are prominent upon observation. The newborn has a relaxed posture. Creases on the feet cover 2/3 of the bottom of the feet.
Pinnae are flexible with rapid recoil. Fingernails are present and extend to the end of the fingers. Creases on the feet cover 2/3 of the bottom of the feet.
A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply. Place the infant on his or her back. Keep the infant dressed warmly at night. Do not allow anyone to smoke around the infant. Let the newborn sleep in the same bed as the parents. Avoid using a pacifier when putting the infant to sleep.
Place the infant on his or her back. Do not allow anyone to smoke around the infant.
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Oxygen is exchanged in the lungs. Fluid is removed from the alveoli and replaced with air. Pressure changes occur and result in closure of the ductus arteriosus. The oxygen in the blood decreases.
Pressure changes occur and result in closure of the ductus arteriosus.
The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective? The newborn's active eye infection resolves. The newborn does not contract ophthalmia neonatorum. The newborn's sclerae do not appear yellow. The newborn is about to produce sufficient tears.
The newborn does not contract ophthalmia neonatorum.
Which statement is true regarding fetal and newborn senses? A newborn cannot experience pain. A newborn cannot see until several hours after birth. A newborn does not have the ability to discriminate between tastes. The rooting reflex is an example that the newborn has a sense of touch. A fetus is unable to hear in utero.
The rooting reflex is an example that the newborn has a sense of touch.
What should the nurse expect for a full-term newborn's weight during the first few days of life? There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies.
Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant? taking a breath within 3 minutes of delivery with stimulation abrupt temperature change upon delivery, causing a cry increase in oxygen levels and decrease in CO2 levels, stimulating respirations rapid respirations following a cesarean birth to eliminate fetal fluids
abrupt temperature change upon delivery, causing a cry
An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? tachypnea cardiac murmur hypoglycemia hyperthermia
tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.
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? "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." "The teeth will fall out within the first month, so don't worry about them." "The teeth will fall out when the newborn's baby teeth come in so this is a blessing."
"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply. Determine the mother's room temperature during the visit. Ask the mother if she fed the newborn while the infant was in the room with her. Turn the nursery temperature up to 80°F (26.7°C). Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.
Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Inform the charge nurse. Call the primary care provider. Document the data. Stimulate the neonate.
Document the data.
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Rocking and talking to the infant Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back
Feeding the infant more formula whenever she begins to fuss
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? The infant may sleep through the night around 2 months of age. Caregivers need to sleep while the baby is sleeping. Newborns usually sleep for 16 or more hours each day. Place the infant on the back when sleeping.
Place the infant on the back when sleeping.
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? Swaddle the infant and place in the bassinet. Complete a full head-to-toe assessment. Assess the newborn's glucose level. Dry the newborn and place it skin-to-skin on mother.
Dry the newborn and place it skin-to-skin on mother.
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: potential for respiratory distress. poor oxygenation. cold stress. acrocyanosis.
acrocyanosis.
A client gives birth to a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? Ensure cool air is circulating over the newborn to prevent overheating. Keep the newborn wrapped in a blanket, with a cap on its head. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm. Keep the infant's room temperature at least 80°F (27°C).
Keep the newborn wrapped in a blanket, with a cap on its head.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Wipe the tongue off vigorously to remove the white patches. Rinse the tongue off with sterile water and a cotton swab. Since it looks like a milk curd, no action is needed. Report the finding to the pediatrician.
Report the finding to the pediatrician.
