The Newborn

Radiation, convection, conduction

3/4 methods of heat loss

A new mother asks the nurse why her newborn must receive a vitamin K injection after birth. Which is the best response made by the nurse? 1 "The medication will allow the newborn to fight any infection acquired." 2 "This is given to all newborns after birth to prevent hemorrhagic disease." 3 "Vitamin K helps prevent complications if exposed to gonorrhea during delivery." 4 "It will decrease the risk of bleeding immediately after birth."

4 Vitamin K is necessary for the formation of clotting factors. It is synthesized by normal flora in the gastrointestinal (GI) tract. Because a newborn's GI tract is sterile at birth, the newborn cannot synthesize vitamin K. Newborns are routinely given a vitamin K injection to decrease the risk of hemorrhage. Vitamin K cannot prevent hemorrhage, nor does it prevent infections

Milia

Benign, keratin-filled cysts that can appear just under the epidermis and have no visible opening.

Prolactin VS Oxytocin

Prolactin and oxytocin are both important hormones in regulation of breastfeeding. Prolactin helps in producing the breast milk and oxytocin stimulates letdown during breastfeeding

Erythema toxicum

(newborn rash) Benign, idiopathic, generalized, transient rash occurring in up to 70% of all newborns during first week of life. Small papules/pustules on skin resembling flea bites. Chief characteristic: lack of pattern. Common on face, chest, back. No needed treatment

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? A 30 mg/dL (1.67 mmol/L) B 53 mg/dL (2.94 mmol/L) C 70 mg/dL (3.89 mmol/L) D 90 mg/dL (5.00 mmol/L)

A. Blood glucose levels less than 50 mg/dL (2.77 mmol/L) is indicative of hypoglycemia in a newborn infant and should be further evaluated and/or treated depending on the individual situation

A newborn 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? A 6 B 7 C 8 D 9

According to the Apgar criteria Acrocyanosis is scored as 1 HR over 100 is scored as 2 Grimace is scored as 1 Some flexion is scored as 1 Weak cry is scored as 1 A. This totals 6 for the 1-minute Apgar score

congenital dermal melanocytosis

Bluish-black areas of hyperpigmentation often found on the lower back or buttocks of darker-skinned neonates

salmon patches

Macular, pink lesions resulting from distended dermal capillaries; usually fade by 1 year of age; common on the nape of the neck, forehead, upper eyelids, or nasolabial folds

The nurse assesses the head circumference of a mature newborn. Which measurement would the nurse identify as a possible cause for concern? A 34.2 cm B 35.2 cm C 36 cm D 37.4.cm

Measurements vary, but in a mature newborn, the head circumference is usually 34 to 35 cm (13.5 to 14 in.). D. A mature newborn with a head circumference greater than 37 cm (14.8 in.) or less than 33 cm (13.2 in.) should be carefully assessed for neurologic involvement, although some well newborns have these measurements

On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is:

Newborn heads are large in proportion to their body, or one-fourth of their total length

Hip dislocation indications

Nonsymmetrical gluteal folds or clicks with joint movement are associated with hip dislocation

Jaundice and 24 hours

Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life

Neonate vitals:

Pulse rate 120 to 160 beats/min Respiratory rate is 30 to 60 breaths/min Temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C). Neonate starts with a low BP 60/40 mm Hg

Caput succedaneum

Soft tissue swelling that occurs from pressure of the presenting part during labor. No interventions are needed; inform the parents that this should improve over the next several days without treatment Diffuse edema of the fetal scalp that crosses the suture lines. Reabsorbed within 1 to 3 days

Cephalohematoma

Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? 1 lack of thoracic compressions during birth 2 loss of blood volume due to hemorrhage 3 inadequate suctioning of the mouth and nose of the newborn 4 prolonged unsuccessful vaginal birth

1 A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? 1 bright red, raised bumpy area noted above the right eye 2 small pink or red patches on the newborn's eyelids and back of the neck 3 fine red rash noted over the chest and back 4 blue or purplish splotches on buttocks

1 A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. 4 Stork bites or salmon patches and blue or purple splotches on buttocks (congenital dermal melanocytosis (slate gray nevi) are common skin variations and are not concerning. 3 Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear within a few days

A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? 1 "We can put him in the tub to bathe him once the cord falls off and is healed." 2 "The cord stump should change from brown to yellow." 3 "Exposing the stump to the air helps it to dry." 4 "We need to call the primary care provider if we notice a funny odor."

2 The cord stump should change color from yellow to brown or black. Therefore the parents need additional teaching if they state the color changes from brown to yellow. NOT 1 Tub baths are avoided until the cord has fallen off and the area is healed. 3 Exposing the stump to the air helps it to dry. 4 The parents should notify their primary care provider if there is any bleeding, redness, drainage, or foul odor from the cord stump.

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? 1 Heart Rate 2 Respiratory Rate 3 Blood Pressure 4 Temperature

3 The blood pressure of a newborn should be quite low—around 60-70 / 35-50. NOT 1.2. The heart rate and respiratory rate are both high, which are normal findings. 4 The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃)

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? 1 nonshivering thermogenesis 2 lack of brown adipose tissue 3 sweating and peripheral vasoconstriction 4 radiation, convection, and conduction

4 Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. NOT 1 Nonshivering thermogenesis is a mechanism of heat production in the newborn. 2 Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. 3 Peripheral vasoconstriction is a method to increase heat production

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? 1 symmetrical chest movements 2 periodic breathing 3 respirations of 40 breaths/minute 4 sternal retractions

4 Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. NOT 1.3. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. 2 Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life

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? 1 tunica albuginea 2 corpus spongiosum 3 rugae 4 prepuce

4 The foreskin or prepuce is a fold of skin which covers the glans of the penis. This fold of skin is removed in a circumcision. NOT 1 The tunica albuginea is connective tissue found inside the penile shaft. 2 The corpus spongiosum is erectile tissue that runs the full length of the penis. 3 Rugae are folds that allow for stretching during an erection

Harlequin sign

A rare color change that occurs between the longitudinal halves of the newborn's body, such that the dependent half is noticeably pinker than the superior half when the newborn is placed on one side; it is of no pathologic significance.

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? A 10% B 12% C 14% D 16%

A. Newborns typically lose approximately 10% of their initial birth weight by 3 to 4 days of age secondary to the loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life

The nurse is preparing to administer an intramuscular injection of vitamin K to a newborn. The nurse will ensure the amount per injection is within which range? A 0.5 to 1.0 mg B 1.25 to 1.75 mg C 2.0 to 2.5 mg D no more than 0.25 mg

A. The efficacy of vitamin K in preventing early vitamin K deficiency bleeding is firmly established and has been the standard of care since the American Academy of Pediatrics (AAP) recommended it in the early 1960s. The AAP (2019) recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg

Suture lines of skull

Cranial sutures are fibrous bands of tissue that connect the bones of the skull. The sutures or anatomical lines where the bony plates of the skull join together can be easily felt in the newborn infant.

Formula fed vs Breastfed stool

If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer.

Assisting in the initiation of breastfeeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding?

This initial feeding should occur during the "first period of reactivity" if the mother and newborn are stable. This phase usually lasts 30 minutes.

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? 1 Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. 2 Harlequin sign noted on left upper outer thigh. 3 Mottling noted on left upper outer thigh. 4 Birth trauma noted on left upper outer thigh

1 A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. NOT 2 The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. 3 Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. 4 Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted

Which statement regarding newborn circumcision is accurate? 1 An advantage of circumcision is a decreased risk of penile cancer. 2 A disadvantage of circumcision is a higher risk of sexually transmitted infections. 3 The American Academy of Pediatrics (AAP) currently discourages circumcision. 4 Newborns do not experience pain during a circumcision

1 Advantages of newborn circumcision are decreased risk of penile cancer and decreased risk of sexually transmitted infections. The AAP states that the health benefits outweigh the risks of newborn circumcision. Research has shown that newborns do experience pain with circumcision

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. 1 women on antithyroid medications 2 women on antineoplastic medications 3 women using street drugs 4 women with more than one infant 5 women who had difficulties with breastfeeding in the past

While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. 1.2.3. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules

Dehydration of newborn: 1 Fontanelles? 2 Eyeballs? 3 Urine output? 4 Energy? 5 Skin? 6 Bodyweight? 7 Mood? Treatement?

1 Sunken fontanels (fontanelles) in a newborn suggest dehydration. Other signs include: 2 sunken eyeballs 3 decreased urine output 4 lethargy 5 creased skin turgor 6 decreased body weight 7 irritability. Tx: Frequent feedings would be used to prevent dehydration.

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? 1 The breakdown of RBCs release bilirubin, which the liver cannot excrete. 2 The GI tract is immature, so the bilirubin remains in the intestines. 3 The newborn's vitamin K levels are low. 4 Feedings are not adequate to eliminate the build-up of bilirubin.

1 After birth, the newborn's hematocrit is about 45% to 65%, which is not needed after birth for oxygenation. The cells then die and are broken down, releasing bilirubin. The liver normally breaks down the bilirubin and eliminates it but since the liver is immature, it becomes overwhelmed and the bilirubin builds up in the bloodstream. NOT 3 Vitamin K levels have no effect on bilirubin levels. 2.4. The immaturity of the GI tract does not cause the bilirubin to increase and feedings do not directly affect bilirubin levels.

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response. 1 "I understand your concern because as many as 50% of babies can develop jaundice." 2 "You don't need to worry about your baby developing jaundice because you are both A+." 3 "If you are concerned about your baby developing jaundice, don't breastfeed your baby until you get home." 4 "We will monitor the baby now, and your baby will not develop jaundice after the first 24 hours of life."

1 As many as 50% of term newborns will develop physiologic jaundice. Physiologic jaundice occurs after the first 24 hours of life and is not pathologic. Pathologic jaundice will develop within the first 24 hours of life

A nurse is providing care to a newborn and places a warm towel on a cold scale to prevent heat loss by which mechanism? 1 conduction 2 evaporation 3 convection 4 radiation

1 Conduction involves the loss of heat through direct contact with an object that is cooler. Placing a warm towel on a cold scale reduces heat loss by this mechanism. NOT 2 Evaporation involves the loss of heat through the conversion of water to its gaseous state. Drying the newborn quickly after bathing reduces heat loss by this mechanism. 3 Convection involves the loss of heat through exchange between two objects within the same environment. Avoiding drafts and using an isolette help reduce heat loss by this mechanism. 4 Radiation involves the loss of heat across a gradient between two objects that are not in direct contact with one another. Not placing a bassinet near cold walls or windows helps reduce heat loss by this mechanism

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? 1 Dry the newborn thoroughly. 2 Put a hat on the newborn's head. 3 Check the newborn's temperature. 4 Wrap the newborn in a blanket.

1 Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. NOT 2.4. Then the nurse would place a cap on the baby's head and wrap the newborn. 3 Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates: 1 normal progression of behavior. 2 probable hypoglycemia. 3 physiological abnormality. 4 inadequate oxygenation

1 From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. NOT 2.3.4. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? 1 lack of subcutaneous fat 2 continual kicking 3 continual crying 4 constriction of blood vessels

1 Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. NOT 4 Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. 2.3. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue? 1 The tint is due to jaundice. 2 Yellow is the normal color for some newborns. 3 The infant needs to be in the sunlight to clear the skin. 4 It's a mild reaction to the vitamin K injection.

1 Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. NOT 2 It is not considered normal and does require assessment and intervention. 3 Phototherapy is the recommended treatment of choice, not putting the child in sunlight. 4 It is not a reaction to the vitamin K injection

Which factor might result in a decreased supply of breast milk in a postpartum client? 1 supplemental feedings with formula 2 maternal diet high in vitamin C 3 an alcoholic drink 4 frequent feedings

1 Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. NOT 2 Vitamin C levels haven't been shown to influence milk volume. 3 One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply isn't necessarily affected. 4 Frequent feedings are likely to increase milk production

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? 1 limited rugae 2 large scrotum 3 palpable testes in scrotal sac 4 negative engorgement

1 Rugae should be well formed and should cover the scrotal sac. NOT 2 The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. 4 There should not be bulging, edema (engorgement), or discoloration. 3 Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.

The nurse notices while holding a 1-day-old infant upright that the baby has a significantly indented anterior fontanel (fontanelle). She immediately brings it to the attention of the health care provider. What does this finding indicate? 1 dehydration 2 increased intracranial pressure 3 vernix caseosa 4 cyanosis

1 The anterior fontanel (fontanelle) can be felt as a soft spot. It should not appear indented (a sign of dehydration)... NOT 2 ...or bulging (a sign of increased intracranial pressure) when the infant is held upright. 3 Vernix caseosa is the white, cream cheese-like substance that serves as a skin lubricant in utero. Some of it is invariably noticeable on a term newborn's skin, at least in the skin folds, at birth. 4 Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? 1 Document this as pseudo menstruation. 2 Notify the health care provider immediately. 3 Obtain a culture of the discharge. 4 Inspect for engorgement.

1 The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated

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? 1 Ask the woman to bring the infant back when the doctor finishes the examination. 2 Call the nursery to confirm the doctor does indeed need this infant at this time. 3 Ask to see the woman' hospital identification badge. 4 Ask how long the infant will be gone since her next feeding is in 30 minutes

1 The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. NOT 2.3.4. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? 1 "It is a normal skin finding in a newborn." 2 "It is a sign of a group B streptococcus skin infection. " 3 "It is an indication that the woman has mistreated her newborn." 4 "It is a self-limiting virus that does not require treatment."

1 This most likely is erythema toxicum, also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment. NOT 3.4.2.This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection This is often mistaken for staphylococcal pustules.

hen caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? 1 rocking and massaging 2 swaddling and positioning 3 using minimal amount of tape 4 using distraction through objects

1 When preterm infants receive sensorimotor interventions such as rocking, massaging, holding, or sleeping on waterbeds, they gain weight faster, progress in feeding abilities more quickly, and show improved interactive behavior. 2.3.4. Interventions such as swaddling and positioning, use of minimal amount of tape, and use of distraction through objects are related to pain management

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? 1 drowsy 2 quiet alert 3 active alert 4 active attentive

2 A newborn that has its eyes open but is quiet and observing people and things around him is in the "quiet alert" state. NOT 3 The active alert state is characterized by the newborn having the eyes open but is moving about. 1 The drowsy state shows the newborn whose eyes are open and closing with heavy eyelids, and the infant is intermittently fussy. 4 There is no "active attentive" state according to the Neonatal Behavioral Assessment Scale.

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? 1 Assess the newborn's gestational age. 2 Rewarm the newborn gradually. 3 Observe the newborn every hour. 4 Notify the primary care provider if the temperature goes lower.

2 A newborn's temperature is typically maintained at 97.7° F to 99.7° F (36.5° C to 37.5° C). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. NOT 1 Assessment of gestational age is completed regardless of the newborn's temperature. 3 Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. 4 The nurse should notify the primary care provider of the newborn's current temperature since it is outside normal parameters

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? 1 "Your newborn should finish a bottle in less than 15 minutes." 2 "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." 3 "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." 4 "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding."

2 A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. NOT 1 The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. 3 The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. 4 The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding

The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect? 1 greenish black, tarry stool 2 yellowish-brown, seedy stool 3 yellow-gold, stringy stool 4 yellowish-green, pasty stool

2 After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. NOT 1 Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. 3 Milk stools of the breastfed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. 4 The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor

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? 1 Recommend that the mother pump her breast milk and measure it before feeding. 2 Breastfeed the infant every 2 to 4 hours on demand. 3 Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. 4 Add cereal to the newborn's feedings twice a day.

2 Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. NOT 3 Normal weight gain for this age infant is 0.66 oz to 1 oz (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). 4 Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. 1 As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition

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? 1 Soak the penis daily in warm water. 2 Cover the glans generously with petroleum jelly. 3 Cleanse the glans daily with alcohol. 4 Notify the primary care provider if it appears red and sore

2 Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. NOT 4 Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. 1 Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. 3 The nurse would not tell the parents to use alcohol on the glans

The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? 1 Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. 2 Excessive fluid in its lungs, making respiratory adaptation more challenging. 3 Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. 4 Much of the fetal lung fluid is squeezed out in cesarean delivery

2 During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean delivery without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. NOT 3 The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. 1 The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: 1 the sleep state. 2 self-quieting ability. 3 social behavior. 4 motor maturity.

2 Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. NOT 1 The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. 3 Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. 4 Motor maturity refers to posture, tone, coordination, and movements of the newborn.

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? 1 The infant is entering the habituation state. 2 The infant is attempting self-consoling maneuvers. 3 The infant is in a state of hyperactivity. 4 The infant is displaying a state of alertness.

2 The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. NOT 1.3.4. The other options are states of behavior of a newborn but are not applicable to this situation.

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? 1 Stools should be yellow-green and loose. 2 Stools should be yellow-gold, loose, and stringy to pasty. 3 Stools should be greenish and formed in consistency. 4 Stools should be brown and loose.

2 The stools of a breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency. The stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? 1 evaporation 2 conduction 3 convection 4 radiation

2 Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. NOT 1 Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. 3 Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. 4 Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: 1 molding. 2 microcephaly. 3 caput succedaneum. 4 cephalohematoma.

3 Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. NOT 1 Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. 2 Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. 4 Cephalohematoma is a localized effusion of blood beneath the periosteum of the skull.

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? 1 Rocking and talking to the infant 2 Swaddling the infant before returning to the crib 3 Feeding the infant more formula whenever she begins to fuss 4 Gently patting or stroking the infant's back

3 Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant

The parents of a 1-day-old newborn are concerned the newborn is cold. Which action should the nurse prioritize to best prevent heat loss? 1 Keep the newborn under the radiant heater when not with mother. 2 Cover the newborn with several blankets while under the warmer. 3 Warm all surfaces and objects that come in contact with the newborn. 4 Bathe and wash the newborn when temperature is 97.5° F (36.4° C).

3 The 1-day-old newborn will have regulated body temperature at this point in life, and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. NOT 1.2. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. 4 Newborns are bathed when their temperatures are stable

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? 1 Recommend a moisturizing soap to clean the nipples. 2 Encourage use of breast pads with plastic liners. 3 Offer suggestions based on observation to correct positioning or latching. 4 Fasten nursing bra flaps immediately after feeding.

3 The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. NOT 1 The client should use only water, not soap, to clean the nipples to prevent dryness. 2 Breast pads with plastic liners should be avoided. 4 Leaving the nursing bra flaps down after feeding allows nipples to air dry

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? 1 Moro 2 tonic neck 3 rooting 4 sucking

3 This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. NOT 1.2. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn

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? 1 after the newborn has received the initial feeding 2 24 hours after admission to the nursery 3 on admission to the nursery 4 4 hours after admission to the nursery

3 Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? 1 Using a 21-gauge needle 2 Injecting 1cc of medication 3 Injecting the medication into the vastus lateralis 4 Injecting at a 45-degree angle

3 Use of the vastus lateralis is the preferred site for administration of the medication. NOT 1. The nurse would use a 22- to 25-gauge needle 2. The nurse would inject 0.5 cc of medication 4 The nurse would inject at a 90-degree angle.

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? 1 lanugo 2 milia 3 vernix 4 amniotic fluid

3 Vernix is the coating on the infant that was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. NOT 1 Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. 2 Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. 4 Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.

The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best? 1 Continue to prepare the newborn for the procedure. 2 Tell the parents the procedure may take more time because of the hypospadias. 3 Give the newborn a sucrose pacifier to reduce pain during the procedure. 4 Inform the practitioner and cancel the procedure.

4 Hypospadias is contraindicated for circumcision. The circumcision is postponed so that the foreskin can be used to repair the hypospadias. Sucrose water can be given for pain relief in circumcision; however, it would not be given if the procedure is cancelled

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? 1 Check the client's blood sugar by a venous blood draw. 2 Feed the newborn some formula immediately. 3 Start an IV to provide intravenous glucose. 4 Perform a heel stick to obtain a blood sample for testing for glucose level

4 If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level.

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? 1 vaginal lacerations 2 increased intracranial pressure 3 cervical lacerations 4 scalp edema

4 Neonatal scalp edema is common after the use of a vacuum extractor. The edema may last up to 7 days. NOT 2.1.3. Increased intracranial pressure is not common, and vaginal or cervical lacerations are problems that may affect the mother.

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: 1 have a smaller body surface compared to body mass. 2 lose more body heat when they sweat than adults. 3 have an abundant amount of subcutaneous fat all over. 4 are unable to shiver effectively to increase heat production

4 Newborns have difficulty maintaining their body heat through shivering and other mechanisms. NOT 1.2. They have a large body surface area relative to body weight and have limited sweating ability. 3 Additionally, newborns lack subcutaneous fat to provide insulation

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis? 1 abundant sole creases 2 minimal vernix caseosa 3 breasts clearly delineated 4 undescended testes

4 Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated (present); and abundant vernix caseosa

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? 1 greenish black with a tarry consistency 2 yellowy mustard color with seedy appearance 3 tan in color with a firm consistency 4 brownish black with a mucus-like appearance

4 The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. 2 If breastfed, the stools will resemble light mustard with seed-like particles. 3 If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? 1 thermoregulatory 2 immunological 3 integumentary 4 cardiopulmonary

4 The newborn undergoes numerous changes in the cardiopulmonary system immediately after birth, such as increased blood flow to the lungs, closure of the patent ductus arteriosus, and closure of the foramen ovale. The newborn takes over gas exchange once the umbilical cord is cut. NOT 1.2.3. Immunological, integumentary, and thermoregulatory systems are all important pieces of the nursing assessment; however, cardiopulmonary is the priority

What should the nurse expect for a full-term newborn's weight during the first few days of life? 1 There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. 2 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%. 3 There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. 4 There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

4 The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.