Nursing Care of the Newborn

After a difficult birth, a neonate has an Apgar score of 4 after 1 minute. Which sign met the criterion of 2 points? 1 Color: pale 2 Respiratory rate: slow 3 Reflex irritability: grimace Correct4 Heart rate: 100 beats/min

A heart rate of 100 beats/min or more is the only criterion that rates a 2 on the Apgar score. The pale color rates a 0. A slow respiratory rate or a weak cry rates a 1. A grimace after testing of reflex irritability rates a 1.

A nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. 1 Crackles Correct2 Cyanosis Incorrect3 Wheezing Correct4 Tachypnea Correct5 Retractions

Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.

A client asks the nurse what advantage breast-feeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1 Amino acids Correct2 Gamma globulins 3 Essential electrolytes 4 Complex carbohydrates

The antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are not required by the infant.

Which newborn assessment finding will probably necessitate prolonged follow-up care? 1 Apgar score of 5 2 Weight of 3500 g Correct3 Umbilical cord with two blood vessels 4 Blood glucose level of 50 mg/dL (1.7 to 3.3 mmol/L

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)

At 42 weeks' gestation a client gives birth to an 8 lb 5 oz (3771 g) newborn. On examining the infant, what does the nurse expect to observe? Select all that apply. Correct1 Long nails Correct2 Wrinkled skin 3 Edematous skin 4 Abundant body hair 5 Obvious blood vessels in the skin

The longer the nails, the more mature the infant. Wrinkled skin is found in a postterm infant who has been exposed to amniotic fluid for too long; the skin is thick, parchmentlike, wrinkled, and peeling. Edematous skin is a characteristic of the preterm infant. Abundant body hair, known as lanugo, is another characteristic of the preterm infant. Obvious blood vessels in the skin are characteristic of the preterm infant because the skin is thin and translucent.

While assessing a newborn, the nurse notes that the infant's skin is mottled. What should the nurse's primary intervention be? 1 Administer oxygen 2 Offer an oral feeding 3 Notify the practitioner Correct4 Warm the environment

Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.

An infant born in a birthing center is being transferred to a regional neonatal intensive care unit because of respiratory distress. Which nursing action best promotes parent-infant attachment? 1 Encouraging the parents to call their infant by name Correct2 Allowing the parents to hold their infant before departure 3 Giving the parents a picture of their infant in the intensive care unit 4 Instructing the parents to contact the neonatal intensive care unit daily

Because seeing and touching the newborn infant are species-specific behaviors for human attachment, allowing the parents to hold the infant will promote bonding. Although encouraging the parents to call the infant by name is a useful action, holding and touching will promote bonding more effectively. After touching and holding, having a picture of their infant in the intensive care unit contributes most to bonding. Actual holding and touching promote bonding more than just hearing about the infant's progress.

While performing bag-and-mask ventilation on a newborn, a nurse does not see the newborn's chest rise. Place the following interventions in order of their priority. Correct 1. Suction the mouth if there are secretions Correct 2. Reposition the head Correct 3. Cover the newborns nose and mouth with the mask Correct 4. Hold the mask using the "E-C clamp" for a better seal Correct 5. Assess the neonate's response to these measures

If the newborn's chest is not rising, first open the mouth and suction if there are secretions. Next, reposition the head. Repositioning the head will help open the airway. Cover the newborns nose and mouth completely with the mask. Hold the mask using the "E-C clamp" for a better seal. The "E & C" is formed by using the fingers and the thumb of the hand. Assess the newborns response to these interventions.

While assessing a newborn the nurse notes the following findings: arms and legs slightly flexed; smooth, transparent skin; abundant lanugo on the back; slow recoil of the pinnae; and few sole creases. What complication does the nurse anticipate in light of these findings? 1 Polycythemia 2 Hyperglycemia 3 Postmaturity syndrome Correct4 Respiratory distress syndrome

The assessment findings are indicative of a preterm infant; therefore the nurse should monitor the infant for signs of respiratory distress syndrome. Polycythemia may develop in a preterm large-for-gestational-age (LGA) infant; however, there are no data to indicate that the infant is LGA. Preterm infants may become hypoglycemic, not hyperglycemic. The neonate is preterm, not postterm.

Two days after birth a neonate's head circumference is 16 inches (41 cm) and the chest circumference is 13 inches (33 cm). What does the nurse infer from these measurements? 1 Microcephaly 2 Narrow chest Correct3 Enlarged head 4 Expected head size

The enlarged head may indicate hydrocephalus. Average head circumference in the healthy newborn is 13.2 to 14 inches (33 to 35 cm), about 1 inch (2.5 cm) larger than the chest circumference. Microcephaly indicates that the head is smaller than expected, not larger. The chest circumference of 13 inches (33 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large.

The nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? 1 Limiting caloric intake to decrease metabolic rate 2 Maintaining the prone position to prevent aspiration 3 Limiting oxygen concentration to prevent eye damage Correct4 Maintaining a high-humidity environment to promote gas exchange

The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible. Caloric intake is increased; the amount, number, and type of feedings are related to the metabolic rate. Infants should be placed in a side-lying rather than a prone position; the prone position is associated with apnea and sudden infant death syndrome. Limiting oxygen concentration to prevent eye damage is not a routine action; the concentration of oxygen depends on the oxygen concentration of the neonate's blood gases.

The nurse is estimating a newborn's gestational age. Which parameters should the nurse utilize when completing her assessment? Select all that apply. Incorrect1 Weight 2 Length Correct3 Breast size 4 Tonic-neck reflex Correct5 Genital development

The presence of breast buds and the development of breast tissue occur at a specific time during gestation and are reliable indicators of gestational age, as is the development of genitalia, which also occurs at a specific time during gestation. Weight and length, which are influenced by both genetics and prenatal stresses, are not accurate indicators of gestational age. The tonic-neck reflex is a primitive reflex found in newborns that disappears at 6 months, but it is not a component of the gestational age assessment.

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? 1 Bacterial infection Correct2 Significant jaundice 3 Bleeding tendencies 4 Adequate oxygenation

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.

At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation? 1 Stimulate crying 2 Substitute sterile water for the formula Correct3 Suction and then oxygenate the newborn 4 Stop the feeding momentarily and then restart it

Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed. Crying may add to the distress. Water could be aspirated, worsening the problem. Stopping the feeding momentarily and then restarting it is unsafe; the newborn is showing signs of a blocked airway.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? Correct1 Warming the newborn 2 Clamping the umbilical cord 3 Assessing maternal bleeding 4 Monitoring expulsion of the placenta

Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. The cord may be left intact until the newborn's temperature has stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother; the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

Which characteristic does the nurse anticipate finding in the newborn of a mother with diabetes? Incorrect1 Irritability Correct2 Flushed skin 3 Hyperreflexivity 4 High-pitched cry

Infants of diabetic mothers (IDMs) are polycythemic and therefore appear flushed; the mechanism underlying this phenomenon is unknown. IDMs generally are placid. These infants are limp, not hyperreflexive. A high-pitched cry is a sign of central nervous system involvement, which is not expected in an IDM.

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? 1 Avoid handling the infant to conserve energy Correct2 Position the infant to promote respiratory efforts 3 Assess the infant for congenital birth defects to enable early treatment 4 Set the incubator thermostat 10° F (12° C) below body temperature to prevent shivering

Positioning the infant with the head slightly hyperextended and changing the position every 1 to 2 hours helps respiratory secretions drain; this will increase oxygenation by enhancing respiratory efforts. Extensive handling is not desired, but infants do need to be touched. All newborns are assessed for congenital birth defects, not just those with RDS. Ten degrees (12 degrees) below body temperature is too low; it may exacerbate the respiratory distress.

A newborn weighing 9 lb 14 oz (4479 g) is delivered by cesarean due to cephalopelvic disproportion. The Apgar scores are 7 at 1 minute and 9 at 5 minutes. Which nursing action should be taken after the initial physical assessment? 1 Administer oxygen by hood Correct2 Determine the blood glucose level 3 Pass a gavage tube for a formula feeding 4 Transfer the newborn to the neonatal intensive care unit

The simple measure of determining the infant's blood glucose level will reveal hypoglycemia in this large-for-gestational-age infant. There are no data that indicate a need for oxygen. Formula will not be given at this time, and there are no data that indicate a need for gavage feeding. The situation does not indicate the need for transfer of the newborn to the neonatal intensive care unit. The Apgar scores demonstrate that this infant is adapting to extrauterine life.

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn? 1 Two vessels: one vein and one artery 2 Three vessels: two veins and one artery 3 Four vessels: two veins and two arteries Correct4 Three vessels: one vein and two arteries

The umbilical cord contains three vessels; one vein carries oxygenated blood to the fetus, and two arteries return deoxygenated blood to the placenta. A cord with two vessels may be associated with congenital abnormalities. If an infant has four vessels: two veins and two arteries, the infant has a cord anomaly.

A nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication should the nurse assess the newborn? 1 Facial palsy 2 Dislocated hip 3 Fractured clavicle Correct4 Intracranial hemorrhage

A rapid birth does not give the fetal head adequate time for molding, so pressure against the head is increased, which may result in intracranial hemorrhage. Facial palsy (paralysis) is caused by pressure on the facial nerve during birth. This is the result of a prolonged second stage of labor or a forceps birth; it does not occur during a precipitous birth. A dislocated hip is more likely to occur in a footling breech birth. A fractured clavicle may occur if pulling on the shoulders during the birth is required.

The primary healthcare provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time? 1 Bringing the infant as requested before she changes her mind 2 Describing how the infant looks before bringing the infant to her Correct3 Staying with her after bringing the infant to help her verbalize her feelings 4 Showing the mother pictures of the birth defects, then bringing the infant to her

Allowing the client time to talk about her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature.

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. 1 The infant cries without noise. Correct2 Aspiration produces a small quantity of light-yellow or light-green liquid. 3 The tube is inserted to a depth from the ear to the tip of the nose to the sternum. 4 A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. Correct5 Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

Aspirated fluid that is either light green or yellow indicates gastric contents. The Nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although the tube being inserted to a depth from the ear to the tip of the nose to the sternum is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.

The nurse determines that a newborn has a cephalhematoma. What did the nurse note? 1 Ridges where the cranial bones overlap 2 Edema involving the scalp over the occipital area 3 Pulsation of the cerebral arteries in the anterior and posterior fontanels Correct4 Bleeding between the parietal bone and periosteum confined within the suture line

Cephalhematoma is a collection of blood localized between the periosteum and the bony cranium caused by the rupture of blood vessels during the birth process; it does not cross suture lines. Overriding sutures cause ridges, not swelling. Edema involving the scalp over the occipital area is a description of caput succedaneum, which results from pressure on the occiput during labor; it is outside the periosteum and spreads throughout the scalp. Pulsations may be seen and palpated in the anterior fontanel, but they are not related to a cephalhematoma.

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action? Correct1 Assessing the infant for signs of pneumonia 2 Securing a prescription for allergy testing of the infant 3 Bathing the infant's eyes with a tepid boric acid solution 4 Teaching the mother to wash her hands before touching the infant

Chlamydia trachomatis is associated with the development of pneumonia in the newborn. Purulent conjunctivitis at this time suggests a Chlamydia infection, not an allergic response. Boric acid solution will not solve this problem; a prescribed antibiotic is required. Teaching the mother to wash her hands before touching the infant would be done eventually; however, the priority is assessing the infant for signs of pneumonia.

The nurse suspects that a newborn's mother contracted rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply. 1 Fever 2 Seizures Correct3 Deafness 4 Conjunctivitis Correct5 Cardiac anomalies

Depending on the specific period of organogenesis when the mother contracted rubella, a variety of defects may occur. Deafness is a typical sign of a newborn affected by a mother who had rubella during early pregnancy. Cardiac anomalies are common in newborns if the mother had rubella during pregnancy during the time of organogenesis. Fever is expected if the mother had an active herpes simplex virus infection or toxoplasmosis at the time of a vaginal birth. Central nervous system problems occur when the mother had toxoplasmosis or an active herpes simplex infection during pregnancy. Conjunctivitis is found in newborns whose mothers had gonorrhea or Chlamydia during a vaginal birth.

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response? 1 "It's such a short procedure that the pain won't last long." 2 "Your baby should have no memory of it, even if there is pain." 3 "A newborn's nerves are not mature enough for him to feel pain." Correct4 "The health care provider will tell you how your baby's pain will be controlled."

Each health care provider has a protocol for relieving the pain caused by circumcision, and the parent has the right to be informed before signing the consent form. Newborns do feel pain, although their nervous systems are not yet mature enough to localize it. The mother is concerned about her newborn's pain regardless of the duration of the procedure. Although the infant may have no memory of the pain, this statement does not address the mother's concern adequately.

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? 1 "It will keep your baby from going blind." 2 "This ointment will protect your baby from bright lights." 3 "There is a law that newborns must be given this medicine." Correct4 "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.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. Which test result should the nurse anticipate for this infant? 1 Increased Po2 2 Lowered HCO3 3 Decreased Pco2 Correct4 Decreased blood pH

In addition to increased Pco2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. Po2 is decreased, because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. Pco2 increases, because inadequate lung surface area is available for the diffusion of gases.

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk for developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. Correct1 Infection 2 Female sex Correct3 Prematurity Correct4 Breast-feeding 5 Formula feeding Correct6 Maternal diabetes

Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Jaundice is more common in male infants. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.

A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply. 1 Isomil Correct2 Phenex Incorrect3 Enfamil 4 Prosobee Correct5 Lofenalac

Phenex is a milk substitute that contains casein hydrolysate, which provides 0.4% phenylalanine. The infant's blood level of phenylalanine must be kept below 8 mg/dL (0.21 mmol/L) to prevent protein catabolism; however, the blood level must remain above 2 mg/dL (0.05 mmol/L) to promote growth and development. Lofenalac is a milk substitute that contains only 0.4% phenylalanine; it is a safe milk substitute for an infant with PKU. Isomil, Enfamil, and Prosobee all contain more than the recommended amount of protein.

An infant born at 36 weeks' gestation weighs 4 lbs 3 oz (1,899 g) and has Apgar scores of 7 and 9. Which nursing actions will be performed upon the infant's admission to the nursery? Select all that apply. Correct1 Recording the neonate's vital signs 2 Administration nasal cannula oxygen 3 Offering a bottle of dextrose in water Correct4 Evaluation of the neonate's health status Correct5 Keeping the neonate's body warm

Recording of vital signs is an important part of recordkeeping for all newborns. All newborns are evaluated on their admission to the nursery. All newborns should be kept warm to maintain a stable body temperature. The neonate's Apgar scores (7 and 9) do not indicate a need for oxygen. Newborns are either breastfed or formula-fed; glucose water is not offered first even for infants with a low blood glucose level. In those cases, glucose is given intravenously.

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include? 1 A schedule for teaching infant care Correct2 A demonstration and explanation of infant care 3 A discussion of mothering skills presented in a nonthreatening manner 4 Emotional support that will foster dependence on the nurse's expertise

Teaching the mother by example is a nonthreatening approach that allows her to proceed at her own pace. Learning does not occur on a schedule; questions must be answered as they arise. New mothers need demonstration of appropriate mothering skills, not just a discussion. Although emotional support is required, the plan should encourage independent caregiving.

A newborn boy is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do? Correct1 Apply the diaper loosely for several days 2 Give a crushed baby aspirin if there is irritability 3 Check for bleeding every 2 hours during the first day home 4 Call the practitioner if there is whitish exudate around the glans

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.

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy? 1 Covering the trunk to prevent hypothermia Correct2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turning after each feeding to reduce exposure of each surface area

The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated, because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? Correct1 Document the stool in the infant's record. 2 Send the stool to the laboratory per protocol. 3 Assess the infant for an intestinal obstruction. 4 Notify the health care provider that a tarry stool has been passed.

The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the health care provider.

The nurse is reevaluating a newborn who had an axillary temperature of 97° F (36.1° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36.1° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? Correct1 Placing the newborn under a radiant warmer in the nursery 2 Checking the newborn for a wet diaper and then continue the skin-to-skin contact 3 Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour 4 Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

The newborn's temperature should be kept in the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C). A hypothermic temperature that has not improved in 1 hour with the use of skin-to-skin contact requires additional measures. The infant should be placed under a radiant warmer for a short time until the temperature returns to the normal range. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia.

The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function? Correct1 Large amounts of urine are excreted. 2 It is the same as in a full-term newborn. 3 Urine is concentrated, with an increased specific gravity. 4 Acid-base and electrolyte balance are adequately maintained

The preterm infant has a reduced glomerular filtration rate and reduced ability to concentrate urine or conserve water. The preterm infant usually has a salt and water diuresis in the first 48-72 hours of life. Preterm infants have a restricted tubular capacity to reabsorb sodium and consequently have large amounts of urine excreted. All systems of the preterm neonate are less developed than in the full-term neonate. Urine is very dilute, not concentrated. Fluid and electrolyte balance in a preterm infant is easily upset.

The health care provider hands a neonate to a nurse immediately after birth. Which is the most appropriate action for the nurse to take next for this newborn? 1 Perform an abbreviated physical assessment 2 Administer oxygen until cyanosis disappears 3 Cut the umbilical cord and attach an umbilical clip Correct4 Dry the infant and provide skin-to-skin contact with the mother

The priority is preventing heat loss; drying the newborn prevents heat loss through evaporation, and skin-to-skin contact with the mother provides a warm environment while promoting attachment. These actions conserve the newborn's oxygen and glycogen reserves. Performing an abbreviated physical assessment is important but not a priority; assessment should be delayed until the infant is warm. Administering oxygen until cyanosis disappears is not necessary because warming the infant will reduce cyanosis if there is no respiratory obstruction. Cutting the umbilical cord and attaching an umbilical clip may be done after provisions have been made to prevent heat loss.

On her first visit to the neonatal intensive care unit to see her preterm newborn, the mother stands 2 feet (61 cm) away and does not touch the infant. The mother's only comment to the nurse is, "My baby looks so fragile. Do you think my child will make it?" What is the most appropriate response by the nurse? 1 "Many infants born as small as yours is have done just fine." 2 "The staff is confident in your child's prognosis, because preterm babies do look like this at first." Correct3 "It's understandable that your baby looks fragile to you. What have you learned about the condition?" 4 "Your baby is not as fragile as it appears. Do you find it so frightening that you can't touch your child?"

The statement "It's understandable that your baby looks fragile to you. What have you learned about the condition?" conveys acceptance by the nurse and encourages the mother to verbalize additional concerns; also, it explores the mother's understanding of the primary healthcare provider's explanation. Comparing the baby to other infants denies the mother the opportunity of further exploration. Telling the mother that the staff members are confident or asking what it is she finds so frightening about her child belittle the mother's concerns and cuts off further communication.

A newborn's total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents? Correct1 A reflex that is expected in the healthy newborn 2 A reflex that remains for the newborn's first year 3 An autonomic reflex indicating that the newborn is hungry 4 An autonomic reflex indicating the newborn's basic insecurity

This is the Moro reflex, which indicates an intact nervous system. The Moro reflex continues as long as the third to sixth month of life; if it persists there may be a neurologic disturbance. This reflex has no relationship to hunger; it is an involuntary response to environmental stimuli.

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants? 1 Have a smaller body surface area than full-term newborns Correct2 Lack the subcutaneous fat that usually provides insulation 3 Perspire excessively, causing a constant loss of body heat 4 Have a limited ability to produce antibodies against infections

Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.

The nurse is caring for a newborn with a caput succedaneum. What is the priority nursing action? Correct1 Supporting the parents 2 Recording neurologic signs 3 Applying a hard protective cap on the head 4 Applying ice packs to the hematoma

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.

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.

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.

At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. What Apgar score should the nurse assign? 1 6 2 7 Correct3 8 4 9

The Apgar score is 8; 1 point is deducted for diminished muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which manifests as bluish hands and feet. Scores of 6 and 7 are too low and a score of 9 is too high.

Which criterion should a nurse use when assessing the gestational age of a preterm infant? 1 Reflex stability 2 Simian creases Correct3 Breast bud size 4 Fingernail length

The size of the breast buds is an indication of gestational age. Small, underdeveloped nipples reflect prematurity. A single palm crease is a clinical manifestation of Down syndrome, not of prematurity. Reflex stability is not a reliable indicator of gestational age; also, reflexes may be impaired in full-term infants. Although the nails may be longer in a postterm infant, nail length is not a reliable indicator in a preterm infant.