Nursing Care of the Newborn

Which factor contributes to the development of physiological jaundice in a newborn?

Immature liver function Rationale: Jaundice occurs because of the expected physiological breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy?

Breaks down the bilirubin into a conjugated form Rationale: Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent?

Evaporation Rationale: Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried. Radiation is the loss of heat to colder solid surfaces that are not in direct contact. Convective heat loss is a result of contact of the exposed skin with cooler surrounding air currents. Conductive heat loss is a result of direct skin contact with a cold solid object.

Which would the nurse discuss with new parents to assist them in preparing for infant care?

Learning specific behaviors involving states of wakefulness to promote positive interactions Rationale: Discussing behaviors during the baby's waking times that will promote positive interaction helps parents understand the unique features of their newborn and promotes interaction and care during periods of wakefulness. A healthy infant's lungs are developed at birth. It is best that infants be on a demand feeding schedule, not a routine schedule. Demand feeding provides for individuality; healthy infants gain weight steadily. Counting the number of stool diapers daily is not a reliable method of determining adequate hydration.

Why should the use of baby powder on an infant be avoided?

Lung irritation Rationale: The use of baby powder or cornstarch should be avoided on an infant because it is associated with lung irritation. The use of baby powder or cornstarch is not directly associated with skin irritation or with skin or respiratory infections.

Where would the nurse find the area of involvement associated with parietal swelling?

On top of the skull Rationale: The parietal areas behind the frontal bone form the top surfaces of the cranial cavity. A swelling in one of these areas that does not cross the suture line is a cephalhematoma. The frontal area is the area over the eyes. The temporal area is the area behind the ears. The occipital area is the area at the back of the head.

Which part of the newborn's foot is the best site to use to obtain blood for the required newborn metabolic testing?

Outer heel Rationale: The outer heel is the preferred site to obtain blood because it 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.

While teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her baby through the placenta?

Passive natural Rationale: 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.

Which information concerning a safe feeding technique would the nurse provide to a mother whose newborn infant son has a cleft lip and palate?

"Give him frequent rest periods and frequent burpings during feedings so he can get rid of swallowed air." Rationale: Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.

The nurse concludes that the parents of a newborn with Erb's palsy have an accurate understanding of the infant's prognosis. Which statement made by the parents confirms this conclusion?

"Recovery usually occurs in about 3 months." Rationale: The arm nerves that are stretched in Erb's palsy, take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis is usually excellent. Physical therapy is necessary for about 3 months, not 1 year.

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How would the nurse respond when the mother asks what is wrong?

"The swelling and discharge are expected. They're a response to your hormones." Rationale: The response "The swelling and discharge are expected. They're a response to your hormones." emphasizes that the findings are to be expected and explains why they occur; this may relieve the client's anxiety. Claiming not to see anything unusual denies that there is anything to explain to the mother and is somewhat belittling. Calling the pediatrician is not necessary; these findings are expected. The comment that the swelling and discharge will go away tells the mother that the findings are expected but provides no explanation and is somewhat belittling.

Which is the range of heart rate for a healthy, alert neonate?

110 to 160 beats/min Rationale: The newborn's heart rate varies with activity; crying can increase it to 180 beats/min, whereas deep sleep may lower it to 80 to 100 beats/min; a rate between 110 and 160 beats/min is the average. A heart rate in an alert, noncrying newborn that is faster than 160 beats/min constitutes tachycardia. The heart rate of an alert, noncrying newborn that is slower than 110 beats/min constitutes bradycardia.

The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches which level?

5 to 7 mg/dL (85.5-119.7 µmol/L) Rationale: Jaundice in a newborn first becomes visible when the serum bilirubin level reaches 5 to 7 mg/dL (85.5-119.7 µmol/L). Jaundice will not be visible at a serum bilirubin level of less than 5 mg/dL (85.5 µmol/L).

Which characteristic would the nurse anticipate in an infant born at 32 weeks' gestation?

Barely visible areolae and nipples Rationale: Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant at 40 to 42 weeks' gestation.

Which action would the nurse take to assist parents with bonding immediately after birth?

Delay applying the antibiotic to the newborn's eyes. Rationale: 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 would assess, not demonstrate, behavior at this time. Footprinting should be done immediately to ensure proper identification of the newborn.

Which assessment finding in a newborn of 33 weeks' gestation alerts the nurse to notify the health care provider?

Flaring nares Rationale: Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and to increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the newborn.

Which factor would the nurse conclude is directly related to an infant's survival in the neonatal period?

Gestational age and birth weight Rationale: Adaptation to the extrauterine environment is largely dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of gestational age and weight. Although the reproductive history of the mother, parental health habits, and social class may all influence health, none of these is critical to neonatal survival. Although adequacy of the mother's prenatal care may influence the mother's health and therefore the fetus's health, it is not as critical to neonatal survival as are an adequate gestational age and birth weight.

Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct.

S Rationale: Findings indicative of abnormal breathing in newborns include stridor, mottling, bradypnea, nasal flaring, and expiratory grunting.

The primary health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. Which nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Staying with her after bringing the infant to help her verbalize her feelings Rationale: Allowing the client time to verbalize 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.

Which method would the nurse use to best elicit the Moro reflex in a full-term newborn?

Striking the surface of the infant's crib suddenly Rationale: Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.

At 10 hours of age a neonate's oral cavity is filled with mucus, and cyanosis develops. Which would the nurse's priority intervention be?

Suction the infant. Rationale: The mucus must be removed via suctioning to maintain a patent airway and promote respirations and gaseous exchange. Oxygenation is ineffective if the airway is obstructed. Documentation is important, but it is not the priority. A nasogastric tube is inserted to aspirate stomach contents, not to clear the airway.

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. Which is the nurse's initial action?

Suctioning the mouth Rationale: To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse's initial action does not clear the airway.

Which is the priority nursing action when caring for a newborn with a caput succedaneum?

Supporting the parents Rationale: Parents need support and reassurance that their newborn is not permanently damaged. Caput succedaneum does not cause impaired neurological function. No special protection of the head is required; routine safety measures are adequate. Caput succedaneum will usually resolve on its own. Ice packs should not be applied to the head.

Which is included in the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy?

Testing for congenital syphilis Rationale: Because physical signs of congenital syphilis are difficult to detect at birth, the infant should be tested immediately to determine whether treatment is necessary. Cleft palate is a congenital defect that occurs in the first trimester; Treponema pallidum does not affect a fetus before the sixteenth week of gestation. Muscle hypotonicity is found in children with Down syndrome, not those with congenital syphilis. Maculopapular lesions of the soles do not manifest in the infant with congenital syphilis until about 3 months of age.