Nursing Care of the Newborn

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds?

Back of the thigh Rationale: With DDH there are extra skinfolds on the affected thigh, a result of the displacement of the head of the femur in the acetabulum. There are no extra folds in the calf muscles, popliteal area, or lower part of the abdomen in DDH.

A new mother tells the nurse that her baby "spits up" after each formula feeding. The nurse teaches her how to position her newborn after feedings. During the next feeding the nurse notes that the mother is positioning the baby correctly. The nurse is observing this activity to:

Confirm that learning has occurred. Rationale: A return demonstration can confirm that the desired learning from earlier teaching has taken place. Teaching has already been done and now must be evaluated. Ascertainment of the mother's knowledge base and readiness to learn is performed during the assessment phase of the nursing process, before teaching, not during the evaluation process.

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?

Esophageal atresia Rationale: Esophageal atresia is associated with hydramnios. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action?

Feeding the infant Rationale: A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. If the hypothermic period is treated adequately, hyperthermia is not expected to develop. The blood count will not change during a transient hypothermic episode. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.

A new mother asks the nurse why her baby seems to have a bowel movement after every feeding. While preparing a response to explain why this is an expected occurrence the nurse remembers that it indicates an adequate:

Gastrocolic reflex response Rationale: The gastrocolic reflex is stimulated when the newborn's stomach begins to fill with fluid; this causes an increase in peristalsis, resulting in the passage of stool during or after a feeding. Six to 10 voidings a day of pale straw-colored urine are indicative of adequate fluid intake, not the frequency of bowel movements. The cardiac sphincter is unrelated to bowel movements; the cardiac sphincter, located between the esophagus and the stomach, is immature in the newborn and is the reason for the newborn's tendency to regurgitate some of the feedings. Although pancreatic amylase is a digestive enzyme, it does not stimulate bowel movements after feedings.

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?

How to monitor their child for signs of jaundice Rationale: 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. The other actions are not specific for a healthy neonate with a cephalhematoma.

A nurse performing a newborn assessment elicits the Babinski reflex. The nurse concludes that finding indicates:

Immaturity of the central nervous system (CNS) Rationale: Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.

The nurse is assessing a 12-hour-old newborn. What clinical finding should be reported to the health care provider?

Jaundice Rationale: Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.

A new mother refuses to look at her newborn, who has a severe birth defect. What is the most therapeutic approach by the nurse?

Reinforcing the explanation of the defect and giving her time to discuss her fears Rationale: The correct approach allows the expression of feelings and clarifies explanations that probably were not heard or understood because of anxiety. Requesting that the family try to distract her prevents the client from facing the problem, thereby increasing her feelings of loss of control. Clarifying why she should stop blaming herself closes off communication by not allowing free expression of grief and assumes that the client blames herself. Waiting until she has sufficiently recovered from the stress of birth supports avoidance of the reality of the situation; it does not solve the problem.

A newborn was delivered 25 minutes earlier. Once identification bands have been applied and vital signs have been taken, what interventions does the nurse need to complete? Place these actions in the order of their priority.

1. Assisting the new mother with breastfeeding 2. Giving erythromycin eye ointment and a vitamin K shot 3. Placing the infant under a warmer and attaching a sensor probe 4. Performing a head-to-toe physical examination 5. Taking and recording weight and height

An adolescent gives birth to an infant with a severe cleft palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate?

"Oh no! This is the wrong baby!" Rationale: Denial or disbelief and shock are considered initial grieving responses. There is a feeling of guilt and inadequacy when an infant is born with a defect. It is unusual for a client to initially verbalize feelings of punishment or guilt so directly. A sense of shame and guilt is voiced later, after denial, disbelief, and shock have occurred. It is unusual for a client to use rationalization and voice it so obviously.

What should the nurse include in the plan of care for a neonate who is undergoing phototherapy?

Discontinuing therapy to hold the infant for feeding Rationale: Holding the infant during feeding is necessary to provide psychosocial contact. Mineral oil is contraindicated because it blocks light rays from acting on bilirubin deposits; frequent cleansing after voiding and defecation prevents skin excoriation. All parts of the body should be exposed to the light. Radiant heaters are not used to reduce bilirubin; fluorescent bulbs are used.