NURSE 420 MATERNITY PREPU

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 lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

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."

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein

How long is the neonatal period for a newborn?

28

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?

Demonstrating how to do cord care on the newborn

To maintain a sufficient fluid intake in a 3-month-old infant, the nurse should make which suggestions to the infant's mother?

Keeping track of the number of wet diapers/day is a good way of knowing the infant is getting enough fluid. The infant will need about 150-200 mL/kg of fluid intake/day. If the breast fed infant is having sufficient wet diapers, she is getting enough fluid.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

Vernix

The Apgar score is based on which 5 parameters?

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

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?

lack of thoracic compressions during birth

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?

6

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply.

A washcloth Warm tub of water Thermometer

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 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

What physiologic changes occur after birth when the cord is cut and clamped?

The infant takes its first breath and the lungs expand to increase blood oxygen levels.

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker."

A young mother is concerned for her baby and asks the LPN if her baby is okay. What is the best response if the nurse notes RR 66, nostrils flaring, and grunting sounds during respiration?

"Your baby is having a little trouble breathing. I'll let the RN know."

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 of 2800 g falls within the normal weight parameters for a full-term newborn.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

Blood sugar 42 mg/dL

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

Breastfeed the infant every 2-3 hours on demand

The nurse is caring for a newborn immediately following birth. Which body system is priorityfor the nurse to monitor during the transition phase?

Cardiopulmonary

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.

A nurse is providing care to a newborn and places a warm towel on a cold scale to prevent heat loss by which mechanism?

Conduction

The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents?

Encourage the parents to pick up the baby

During an assessment, the nurse suspects a newborn has a chromosomal disorder. What did the nurse most likely assess in the baby?

Low-set ears

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?

Mongolian spot

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Mongolian spots.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

Which action will the nurse avoid when performing basic care for a newborn male?

Retracting the foreskin over the glans to assess for secretions

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

Rooting

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?

conduction

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production?

nonshivering thermogenesis

The nurse is answering questions from a newborn's parents concerning a circumcision. Which structure will the nurse point out is removed during the procedure?

prepuce

A new mother voices concerns about breastfeeding her infant. The nurse would explain to the mother the two hormones that control lactation and letdown are:

prolactin and oxytocin.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited?

rooting

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

yellowish gold color stringy to pasty consistency