16. Newborn

apgar scoring

-7-10 = newborn is adjusting well to extrauterine life -4-6 = requires some resuscitative interventions ->3 = requires vigorous resuscitation

lanugo

-fine downy hair -usually found on pinnae of ears, forehead, shoulders -preemies have more than term babies

thermoregulation: convection

-flow of heat from the body surface to cooler environmental air -shield newborn from draft (swaddle in blanket, cover head) -procedures with newborn uncovered should be performed under radiant heat source

substance withdrawal symptoms: other (8)

-high-pitched cry -irritability -sweating -fever -tremors -hyperactivity -hypertonicity -exaggerated reflexes

cold stress symptoms (5)

-hypothermia (<36.5°C / 97.7°F) -tachypnea -cyanosis -hypoglycemia -metabolic acidosis

pathologic jaundice

-result of an underlying disease -within 24 hrs after birth -persists after day 14

normal respiratory characteristics (2)

-short periods of apnea lasting <15 sec -nose breathers

cephalohematoma

-swelling caused by bleeding between skull bone and periosteum -usually resolves in 2-3 weeks -crosses suture line

hypoglycemia symptoms (7)

-twitching, tremors, jitteriness -weak cry -poor feeding -hypothermia -lethargy -cyanosis -seizures

Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? (Select all that apply.) 1. 10 to 20 mL is the stomach capacity of a 1-day-old newborn 2. 30 to 60 mL is the stomach capacity of a 1-day-old newborn 3. 75 to 100 mL is the stomach capacity of a 1-week-old infant 4. 90 to 150 mL is the stomach capacity of a 1-month-old infant 5. 250 to 400 mL is the stomach capacity of a 1-month-old infant

1. 10 to 20 mL is the stomach capacity of a 1-day-old newborn 4. 90 to 150 mL is the stomach capacity of a 1-month-old infant (The stomach capacity is 10-20 mL for a newborn infant, 30-60 mL for a 1-week-old infant, 75-100 mL for a 2- to 3-week-old infant, and 90-150 mL for a 1-month-old infant.) NCLEX

A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

1. Encourage the parents to touch their newborn. NCLEX

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings should the nurse most specifically expect to note in the infant? (Select all that apply.) 1. Failure to thrive 2. Excessive oral secretions 3. Bowel sounds heard over the chest 4. Hiccups and spitting up after a meal 5. Coughing, wheezing, and short periods of apnea

1. Failure to thrive 5. Coughing, wheezing, and short periods of apnea NCLEX

Which is considered a normal finding in a newborn less than 12 hours old? 1. Has not passed meconium yet 2. Seesaw respirations of 28 breaths/minute 3. Total serum bilirubin level of 15.2 mg/dL 4. White blood cell (WBC) count of 50,000 mm³

1. Has not passed meconium yet -meconium may not be passed for 24-48 hrs -seesaw respirations indicate a respiratory problem -bilirubin level is excessive for a newborn -WBC count is excessive for a newborn NCLEX

A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? (Select all that apply.) 1. Irritability 2. Failure to thrive 3. Choking with feeding 4. Excessive weight gain 5. Spitting up and regurgitation

1. Irritability 2. Failure to thrive 3. Choking with feeding 5. Spitting up and regurgitation (GER assessment findings include irritability, failure to thrive, choking with feeding, weight loss, and spitting up and regurgitation. Weight loss, not weight gain, is typical of this condition due to frequent refusal to eat.) NCLEX

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect? 1. Low set ears 2. Vernix caseosa 3. A 5-cm anterior fontanel 4. A heart rate of 130 beats per minute

1. Low set ears NCLEX

An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1. Palpate the clavicles for a fracture. 2. Auscultate the heart for a cardiac defect. 3. Blanch the skin for evidence of jaundice. 4. Perform Ortolani's maneuver for hip dislocation.

1. Palpate the clavicles for a fracture. NCLEX

The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? 1. Presence of a cephalhematoma 2. Infant blood type of O negative 3. Birth weight of 8 pounds 6 ounces 4. A negative direct Coombs' test result

1. Presence of a cephalhematoma NCLEX

The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? (Select all that apply.) 1. Protect defect from trauma. 2. Protect sac or viscera with dry gauze. 3. Maintain a thermoneutral environment. 4. Feed newborn every 4 hours, 2 to 3 ounces (60 to 90 ml) of D5W. 5. Assess for associated birth defects such as cleft palate.

1. Protect defect from trauma. 3. Maintain a thermoneutral environment. 5. Assess for associated birth defects such as cleft palate. Omphalocele is an abdominal wall defect - the viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane -cover with saline-soaked gauze -newborn should be NPO -increased risk for cleft lip and/or cleft palate. NCLEX

A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest, with acrocyanosis

1. Tachypnea and retractions NCLEX

normal weight

2,500-4,000 g (5.5-8.75 lb)

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? (Select all that apply.) 1. Retinopathy 2. Hypoglycemia 3. Fractured clavicle 4. Hyperbilirubinemia 5. Congenital heart defect 6. Necrotizing enterocolitis

2. Hypoglycemia 3. Fractured clavicle 5. Congenital heart defect NCLEX

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2. Maintaining safety because of low blood glucose levels NCLEX

The nurse creates a plan of care for a woman with HIV and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2. Maintaining standard precautions at all times while caring for the newborn NCLEX

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate? 1. Folic acid 2. Phenytoin 3. Bupropion 4. Methyldopa

2. Phenytoin NCLEX

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex? 1. Clap hands or slap the mattress. 2. Stimulate the perioral cavity with a finger. 3. Stimulate the ball of the infant's foot with firm pressure. 4. Stimulate the pads of the infant's hands with firm pressure.

2. Stimulate the perioral cavity with a finger. NCLEX

The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels

3. Blood glucose levels (most common metabolic complication in SGA newborn is hypoglycemia) NCLEX

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1. Reinforce the dressing. 2. Document the findings. 3. Contact the health care provider. 4. Swab the drainage and send the sample to the laboratory for culture.

3. Contact the health care provider. (fever and a purulent or foul-smelling drainage = infection) NCLEX

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment? 1. Heart rate 90 beats/min, respirations 46 breaths/min 2. Heart rate 120 beats/min, respirations 68 breaths/min 3. Heart rate 130 beats/min, respirations 46 breaths/min 4. Heart rate 180 beats/min, respirations 56 breaths/min

3. Heart rate 130 beats/min, respirations 46 breaths/min -normal heart rate = 110-160 beats/min -normal respirations = 30-60 breaths/min NCLEX

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2. The newborn is adjusting well to extrauterine life. 3. The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life.

3. The newborn requires some resuscitative interventions. (Apgar score 5-7 often indicates that the newborn requires some resuscitative interventions) NCLEX

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's highest priority at this time is to perform which action? 1. Auscultate the heart rate. 2. Determine the Apgar score. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature.

3. Thoroughly dry the newborn. NCLEX

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? (Select all that apply.) 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches. NCLEX

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.

4. Monitor the newborn's response to feedings and weight gain pattern. NCLEX

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Cover the ears with gauze pads. 4. Notify the health care provider.

4. Notify the health care provider. (Low or oddly placed ears are associated with various congenital defects and should be reported immediately) NCLEX

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1. Call bell 2. Feeding pump 3. Vital sign machine 4. Phototherapy lights 5. Intravenous (IV) pump

4. Phototherapy lights 5. Intravenous (IV) pump (The phototherapy lights must be used continually to be effective. Given the fact that the newborn is 4 days old, accurate delivery and prevention of circulatory overload is a priority. The IV fluid rate must be maintained using an IV pump.) NCLEX

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is frequently seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C."This is a forceps mark from an operative delivery." D."This is related to prolonged birth or trauma during delivery."

A. "This is frequently seen in newborns who have dark skin." (Mongolian spots) ATI

A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. which of the following are expected findings in this newborn? (select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face

A. Lanugo C. Weak grasp reflex D. Translucent skin ATI

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high‐pitched cry." C."The newborn will sleeps for 2 to 3 hours after a feeding." D."The newborn will have mild tremors when disturbed."

B. "The newborn will have a continuous high‐pitched cry." ATI

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age

B. Appropriate for gestational age -normal weight = 2,500-4,000 g -appropriate = 10th-90th percentile ATI

A nurse is completing an assessment. which of the following data indicate the newborn is adapting to extrauterine life? (select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10‐second periods D. Obligatory nose breathing E. Crackles and wheezing

C. Apnea for 10‐second periods D. Obligatory nose breathing ATI

A nurse is assessing a 2 day old newborn and notes an egg shaped, edematous bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding? a. "This will resolve within 3-6 weeks without treatment." b. "This will resolve on its own within 3-4days." c. "The provider might drain this area with a syringe." d. "This is expected at birth so you don't need to worry about it."

a. "This will resolve within 3-6 weeks without treatment." (cephalhematoma) ATI

Which of the following physical assessment findings indicates a need for further evaluation? a. Absence of the rooting reflex b. Hypertonia c. Brisk knee jerk d. Plantar flexion

a. Absence of the rooting reflex (Absence or delayed disappearance of reflexes will always be a concern and a reason to refer for developmental screening. Newborns tend to have more hypertonia than hypotonia. Hypotonia would be a definite need for a referral. Brisk knee jerk and plantar flexion should be found upon exam of the newborn.) text

A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect? a. Abundant lanugo. b. Good flexion. c. Heel creases covering the bottom of feet. d. Dry, parchment like skin.

a. Abundant lanugo. preemies: -hypotonia -few heel creases -vernix ATI

A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider? a. Jaundice of the sclera b. Respiratory rate 50/min c. Acrocyanosis d. Blood glucose 60mg/dL

a. Jaundice of the sclera -normal respiratory rate = 30-60 breaths/min -acrocyanosis is normal -normal glucose level = 40-60 mg/dL ATI

Which of the following may cause convection heat loss in the newborn? a. Removal from an incubator for procedures b. Placing cold objects, such as ice, onto the radiant warmer bed c. Inadequate drying d. Using a cold stethoscope

a. Removal from an incubator for procedures (convection = loss of body warmth to cooler air) text

Signs of cold stress in newborns include (select all that apply): a. increased respirations b. decreased respirations c. increased skin temperature d. decreased skin temperature e. hypoglycemia f. hyperglycemia

a. increased respirations d. decreased skin temperature e. hypoglycemia quiz

postmature/post-term

after 42 weeks gestation

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first? a. Perform a detailed physical assessment b. Place the newborn directly on the client's chest. c. Give the newborn Vitamin K IM. d. Administer erythromycin ophthalmic ointment.

b. Place the newborn directly on the client's chest. (nurse should perform detailed physical assessment within 12-18 hrs) ATI

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect? a. bruising over the buttocks b. hard modules on the roof of the mouth c. petechiae over the head d. bilateral periauricular papillomas

c. petechiae over the head ATI

A frequent blood glucose test may be indicated for which newborn? a. A newborn with increased temperature and increased heart rate b. A newborn that is inconsolable c. A newborn with suspected hypothyroidism d. A newborn that is large for gestational age

d. A newborn that is large for gestational age text

The nurse is examining an infant at 1 hour of life and notes a small, flat, pink lesion between the eyebrows that becomes more pronounced with crying. This should be documented as a(n): a. Nevus flammeus. b. Nevus vasculosus. c. Erythema toxicum. d. Telangiectatic nevus.

d. Telangiectatic nevus. text

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? a. extended periods of sleep b. poor muscle tone c. respiratory rate 50/min d. exaggerated reflexes

d. exaggerated reflexes neonatal abstinence: -hyperactivity -hypertonicity -tachypnea (>60 breaths/min) ATI

A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? a. promoting maternal-newborn bonding b. tight swaddling of the newborn c. small frequent feedings d. frequent stimulation

d. frequent stimulation (newborn needs quiet, calm environment to promote rest and reduce stress) ATI

A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia? a. hypertonia b. increased feeding c. hyperthermia d. respiratory distress

d. respiratory distress (Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures) ATI

Moro reflex

elicit by allowing the head and trunk of the newborn in a semisitting position to fall backward - the newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a "C"

plantar grasp

elicit by placing finger at base of newborn's toes - toes curl downward

palmar grasp

elicit by placing finger in palm of newborn's hand - fingers curl around examiner's fingers

flashcards

https://www.freezingblue.com/flashcards/print_preview.cgi?cardsetID=256739

bulb syringe suctioning

mouth 1st, nose 2nd

apgar

physical exam done 1 min and 5 min after birth

Epstein's pearls

small white cysts on gums and hard palate

Ortolani's sign

hip click - sign of hip dysplasia

premature/pre-term

20-37 weeks gestation

normal glucose level

40-60 mg/dL

A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate

A. Oxygen saturation ATI

A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap

D. Covering the newborn's head with a cap ATI

A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. this finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls

D. Epstein's pearls ATI

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? a. Legs that are shorter than the arms. b. Temperature of one leg different from that of the other. c. Symmetrical gluteal folds. d. Limited abduction of one hip.

d. Limited abduction of one hip. ATI

A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? a. assign Apgar scores to the newborn b. weigh the newborn c. place identification bracelets on the newborn d. dry the newborn

d. dry the newborn ATI

posterior fontanel: size and shape

-0.5-1 cm -triangular

microcephaly

-abnormally small head -head circumference is ≤32 cm

telangiectatic nevi

-aka "stork bites" -flat pink or red marks that easily blanch -back of neck, nose, upper eyelids, middle of forehead

physiologic jaundice

-benign -72-120 hrs after birth

Mongolian spots

-bluish purple spots of pigmentation (like bruises) -shoulders, back, butt -more common in newborns with dark skin

A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. Rooting b. Moro c. Tonic Neck d. Babinski

c. Tonic Neck ATI

when do you reassess apgar at 10 min?

if apgar <7

A nurse is assessing a 4 hour old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? a. Apply an oxygen hood over the newborn's head and neck. b. Check the newborn's temperature using a temporal thermometer. c. Place the naked newborn on the mother's bare chest and cover both with a blanket. d. Give the newborn glucose water between feedings.

c. Place the naked newborn on the mother's bare chest and cover both with a blanket. (skin-to-skin stabilizes temperature) ATI

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding? 1. Provide oxygen via nasal cannula. 2. Contact the health care provider. 3. Reassess the respiratory rate in 15 minutes. 4. Document the findings in the electronic health record.

4. Document the findings in the electronic health record. (normal respiratory rate = 30-60 breaths/min) NCLEX

milia

-small raised white dots on skin -nose, chin, forehead

sepsis symptoms: vitals (3)

-tachycardia -tachypnea -hypothermia, temperature instability

substance withdrawal symptoms: respiratory (4)

-tachypnea -respiratory distress -sneezing -nasal congestion

normal umbilical cord

3 vessles: -2 arteries -1 vein

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1. Make a loud, abrupt noise to startle the newborn. 2. Stimulate the ball of the foot of the newborn by firm pressure. 3. Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure.

1. Make a loud, abrupt noise to startle the newborn. -ball of foot = plantar reflex -perioral cavity = rooting reflex -pads of hands = palmar reflex The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar pattern). NCLEX

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which assessment findings should the nurse expect to note in the neonate? (Select all that apply.) 1. Tremors 2. Tachycardia 3. Flaccid muscles 4. Extreme lethargy 5. Exaggerated startle reflex

1. Tremors 2. Tachycardia 5. Exaggerated startle reflex Clinical signs and symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea. NCLEX

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? (Select all that apply.) 1. Tremors 2. Lethargy 3. Irritability 4. Poor feeding 5. Higher-than-normal birth weight 6. A greater-than-normal appetite when feeding

1. Tremors 3. Irritability 4. Poor feeding NCLEX

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10 NCLEX

The mother of a preterm newborn is comparing the appearance of her preterm baby to the nearby full-term babies. She asks why her baby's skin appears so different. What is the best response for the nurse to provide? 1. "A full term newborn has decreased brown fat stores." 2. "A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat." 3. "A preterm baby has additional subcutaneous fat beneath the skin that is lost between 38 to 40 weeks." 4. "The full term newborn has produced much more soft downy hair, giving the skin a more fuzzy appearance."

2. "A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat." NCLEX

A newborn infant of a mother who has HIV is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection 3. Indicates that the newborn will develop AIDS later in life 4. Positive for acquired immunodeficiency syndrome (AIDS)

2. Indicates the presence of maternal infection (A positive antibody test in a child <18 months indicates only that the mother is infected because maternal immunoglobulin G antibodies persist in infants for 6-9 months and, in some cases, for as long as 18 months) NCLEX

The nurse is monitoring a newborn born to a client who abuses alcohol. Which findings should the nurse expect to note when assessing this newborn? (Select all that apply.) 1. Flaccidity 2. Irritability 3. Minimal response to stimuli 4. Greater than normal birth weight

2. Irritability 3. Minimal response to stimuli NCLEX

Which newborn is most at risk for a brachial plexus injury? 1. A term infant with a history of a forceps-assisted delivery 2. A term infant delivered via primary cesarean section for malpresentation 3. A large for gestational age infant with a history of shoulder dystocia at delivery 4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes

3. A large for gestational age infant with a history of shoulder dystocia at delivery NCLEX

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? (Select all that apply.) 1. A bulging anterior fontanel 2. A depressed anterior fontanel 3. A soft and flat anterior fontanel 4. A triangular-shaped anterior fontanel 5. A triangular-shaped posterior fontanel 6. Size of posterior fontanel is 4 cm by 6 cm

3. A soft and flat anterior fontanel 5. A triangular-shaped posterior fontanel -anterior fontanel: diamond shaped, soft and flat, 4-5 cm across -posterior fontanel: triangular shaped, 1cm x 2cm NCLEX

A newborn was not dried completely after birth. Which of the following mechanisms should the nurse understand causes heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

C. Evaporation (loss of heat that occurs when liquid is converted to vapor) ATI

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? 1. Loose stools 2. High-pitched cry 3. Vigorous feeding habits 4. A copper-colored skin rash

4. A copper-colored skin rash NCLEX

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1. Initiate an intravenous (IV) line on the newborn infant. 2. Place the newborn infant on a cardiorespiratory monitor. 3. Place the newborn infant in the radiant warmer incubator. 4. Administer oxygen via resuscitation bag to the newborn infant.

4. Administer oxygen via resuscitation bag to the newborn infant. NCLEX

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1. A suture split greater than 1 cm 2. A hard, rigid, immobile suture line 3. Swelling of the soft tissues of the head and scalp 4. Edema resulting from bleeding below the periosteum of the cranium

4. Edema resulting from bleeding below the periosteum of the cranium NCLEX

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? 1. Dry the newborn's head thoroughly. 2. Turn the thermostat in the room to 70°F. 3. Place the newborn near the nursery window. 4. Place a warm blanket on the examining table before placing the newborn on the table.

4. Place a warm blanket on the examining table before placing the newborn on the table. (conduction: heat loss occurs when the infant is on a cold surface) NCLEX

normal length

45-55 cm (18-22 in)

A nurse is taking a newborn to a mother following a circumcision. Which of the following actions should the nurse take for security purposes? A. Ask the mother to state her full name. B. Look at the name on the newborn's bassinet. C. Match the mother's identification band with the newborn's band. D. Compare name on the bassinet and room number.

C. Match the mother's identification band with the newborn's band. ATI

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash

C. Sunken fontanels ATI

nervus flammeus

-aka "port wine stain" -commonly appears on face -does not fade

A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi‐sitting position, then allow the newborn's head and trunk to fall backward.

D. Hold the newborn in a semi‐sitting position, then allow the newborn's head and trunk to fall backward. ATI

thermoregulation: evaporation

-loss of heat as surface liquid is converted to vapor -dry newborn immediately after delivery

thermoregulation: radiation

-loss of heat from the body surface to a cooler surface that is close, but not in direct contact -keep newborn away from cold objects and outside walls

hypoglycemia risk factors (4)

-maternal diabetes -preterm infant -LGA -SGA

molding

-overlapping head sutures from pressure in birth canal -resolves in about 72 hrs

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP).

3. Document the findings. NCLEX

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket NCLEX

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?

-1 minute after birth -5 minutes after birth

anterior fontanel: size and shape

-5 cm -diamond-shaped

hydrocephalus

-excessive cerebral fluid within the brain cavity surrounding the brain -head circumference is ≥4cm larger than chest circumference

caput succedaneum

-localized swelling of soft tissues of the scalp -usually resolves in 3-4 days -does not cross suture line

thermoregulation: conduction

-loss of body heat resulting from direct contact with a cooler surface -perform all treatments on a warm, padded surface

A nurse is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? (Select all that apply) 1. cyanosis 2. tachypnea 3. hypotension 4. retractions 5. audible grunts 6. presence of a barrel chest

1. cyanosis 2. tachypnea 4. retractions 5. audible grunts NCLEX

normal heart rate

110-160 bpm

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

2. Abnormal palmar creases NCLEX

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? 1. Wrap the paper tape around the newborn's head, and measure just above the eyebrows. 2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. 3. Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth. 4. Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.

2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. NCLEX

Which are considered normal findings in a newborn less than 12 hours old? (Select all that apply.) 1. Grunting respirations 2. Presence of vernix caseosa 3. Heart rate of 190 beats/minute 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet 6. Yellow discoloration of the sclera and body

2. Presence of vernix caseosa 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet NCLEX

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? (Select all that apply.) 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

3. Irritability 4. Constant crying 5. Difficult to comfort NCLEX

The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1. Thin and gelatinous, with increased subcutaneous fat 2. Thin and gelatinous, with increased amounts of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat

3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat NCLEX

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1. One artery 2. Two veins 3. Two arteries 4. One artery and one vein

3. Two arteries NCLEX

normal chest circumference

30-33 cm (12-13 in)

normal respiratory rate

30-60 breaths/min

normal head circumference

33-35 cm (13-14 in) (NCLEX, text) 32-37 cm (12.5-14.5 in) (ATI) (should be 2-3 cm larger than chest circumference)

normal temperature

36.5-37.5°C (97.7-99.5°F)

normal blood pressure

60/40-80/50 mm Hg (ATI) 80/40-90/50 mm Hg (NCLEX) 50/30-70/45 mm Hg (OB text)

hypoglycemia glucose level

<40 mg/dL

hyperbilirubinemia: bilirubin level

>12 mg/dL (NCLEX)

What would be considered an abnormal finding upon the initial physical assessment of the newborn? a. A two-vessel cord b. APGARs of 8 at 1 minute and 9 at 5 minutes c. Newborn required suctioning of the mouth and nares immediately after delivery. d. Loud, continued crying

a. A two-vessel cord text

Clinical manifestations that indicate a newborn may be experiencing overheating include: a. Increased heart rate, increased blood pressure, and increased restlessness. b. Decreased blood pressure and lethargy. c. Increased respiratory rate, perspiration over forehead and torso, and decreased blood pressure. d. Increased heart rate, increased blood pressure, decreased oxygen consumption.

a. Increased heart rate, increased blood pressure, and increased restlessness. text

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply) a. heart rate 154/min b. axillary temperature 36°C (96.8°F) c. respiratory rate 58/min d. length 43 cm (16.9 in) e. weight 2.6 kg (5 lb 12 oz)

a. heart rate 154/min c. respiratory rate 58/min e. weight 2.6 kg (5 lb 12 oz) -normal temp = 36.5-37.5°C (97.7-99.5°F) -normal length = 45-55 cm (17.7-21.7 in) ATI

A nurse is caring for four newborns. Which of the newborns is at greatest risk for hypoglycemia? a. newborn who is large for gestational age b. newborn who has Rh incompatibility c. newborn who has pathologic jaundice d. newborn who has fetal alcohol syndrome

a. newborn who is large for gestational age ATI

The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a. Traumatic birth b. Maternal substance abuse c. Sepsis d. Gestational diabetes

b. Maternal substance abuse text

When an infant is placed on the mother's abdomen, he is not moving his extremities, although they are slightly flexed. The hands and feet are blue. He cries momentarily, but is making good respiratory effort with no use of accessory muscles. He grimaces and sticks out his tongue when the nurse-midwife wipes his face. She states the cord pulse is 130. What is this baby's 1-minute Apgar score? a. 5 b. 7 c. 9 d. 10

b. 7 Activity = 1 (extremities flexed) Pulse = 2 (>100 bpm) Grimace = 1 Appearance = 1 (blue extremities) Respiration = 2 text

What are appropriate nursing actions for facilitating family-newborn attachment? (Select all that apply.) a. Take the newborn to the nursery for periods of sleep. b. Assist with an interactive bath. c. Take the newborn to the nursery for IV antibiotic therapy. d. Encourage sibling visitation whenever possible.

b. Assist with an interactive bath. d. Encourage sibling visitation whenever possible. text

To create a neutral thermal environment for a newborn immediately after delivery, the nurse should consider: a. Deep suction every hour while under the radiant warmer bed. b. Providing care and assessments while the infant is skin-to-skin on the mother's chest. c. Placing the newborn with the extremities extended and relaxed under the radiant warmer bed. d. Placing the newborn with the extremities extended and relaxed, and placing a hat over the newborn's head.

b. Providing care and assessments while the infant is skin-to-skin on the mother's chest. text

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.) a. yellow sclera b. creases over two-thirds of the soles of the feet c. posterior fontanel larger than anterior fontanel d. molding of the head e. lanugo on the shoulders

b. creases over two-thirds of the soles of the feet d. molding of the head e. lanugo on the shoulders ATI

The nurse is called to a postpartum room by a mother who is worried about her baby's irregular breathing. What is the best explanation the nurse can give? a. "Notify the nurse whenever you see that, because infants can develop respiratory distress very quickly." b. "You can assume the baby is fine unless he is lethargic." c. "Irregular breathing and pauses up to 20 seconds are normal for a newborn." d. "Irregular breathing is normal as long as the total is at least 20 breaths per minute."

c. "Irregular breathing and pauses up to 20 seconds are normal for a newborn." text

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn? a. 7 b. 8 c. 9 d. 10

c. 9 -blue hands and feet = 1 -heart rate 136/min = 2 -response to stimuli = 2 -flexed extremities = 2 -cry = 2 ATI

A newborn appears large for gestational age, while a lower score for neurological maturation is noted on gestational exam. Which answer best explains this outcome? a. Maternal preeclampsia b. Maternal analgesia and anesthesia c. Maternal hypertension d. Maternal diabetes

d. Maternal diabetes (Maternal diabetes accelerates fetal growth, but retards maturation. Maternal hypertension retards physical growth and speeds maturation. Maternal analgesia causes respiratory depression. Maternal preeclampsia causes active muscle tone and edema.) text

What is the most appropriate nursing action for a newborn demonstrating acrocyanosis? a. Administer IV fluids. b. Suction vigorously. c. Place in the Trendelenburg position. d. Swaddle in blankets.

d. Swaddle in blankets. (Acrocyanosis is caused by poor peripheral circulation and is a normal finding in the first 2 days of life. Keeping the hands and feet warm will increase perfusion to the periphery.) text

Babinski reflex

elicit by stroking outer edge of sole of the foot, moving upward toward toes - toes will fan upward and out

rooting reflex

elicit by stroking the cheek or edge of mouth - newborn turns head toward that side and begins to suck

phototherapy

use of light to reduce serum bilirubin levels in the newborn

sepsis symptoms: other (4)

-pallor -poor feeding -abdominal distention -suspicious drainage (eyes, umbilical stump)

erythema toxicum

-pink rash that appears suddenly anywhere on the body of a term newborn in the first 3 weeks -aka "newborn rash" -no treatment required

neonatal substance withdrawal symptoms: GI (4)

-poor feeding -diarrhea -vomiting -excessive, uncoordinated sucking

respiratory distress symptoms (5)

-tachypnea -nasal flaring -expiratory grunting -retractions -apnea

The nurse attends the birth of a healthy, term baby at 7:15 p.m. The mother has expressed a desire to breastfeed. When is the best time to assist her with the baby's first feeding? a. Immediately, before the cord is cut b. Between 7:45 and 8 p.m. c. After 2 hours, when recovery is over and she is settled in a postpartum bed d. Any time before the baby receives any bottles or artificial nipples

b. Between 7:45 and 8 p.m. (The 1st period of reactivity in the newborn occurs between 30 min-1 hr after birth. The baby will be in a quiet, alert state at this time, which is ideal for feeding. Breastfeeding may be initiated immediately if the mother wishes but is likely to be disrupted by the necessary assessments of mother and baby that occur immediately after birth.) text

hypoglycemia symptoms: respiratory (4)

-tachypnea -irregular respirations -respiratory distress -apnea

A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what should she expect because her baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C."Your baby's heels will easily move to his ears." D."Your baby's skin will have a leathery appearance."

D."Your baby's skin will have a leathery appearance." ATI

A newborn has developed physiologic jaundice and hyperbilirubinemia. Which of the following supportive measures would be most effective at helping to decrease bilirubin levels? a. Give the baby a bottle of water. b. Place the baby under a radiant warmer. c. Assist with and facilitate frequent breastfeeding. d. Make the newborn NPO.

c. Assist with and facilitate frequent breastfeeding. text

A nurse is assessing a 12 hour old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take? a. Perform chest percussion. b. Place the newborn in a prone position. c. Continue routine monitoring. d. Request a prescription for supplemental oxygen.

c. Continue routine monitoring. (normal = 30-60 breaths/min with periods of apnea) ATI

Which rationale best describes the intervention of suctioning a baby's mouth and nares immediately after delivery? a. Suctioning decreases intrathoracic pressure, decreasing the respiratory rate to 30-60 breaths per minute. b. Suctioning assists with increasing the pulmonary vascular resistance in the lungs, resulting in a decrease in blood flow to the pulmonary bed. c. Suctioning removes fluid that remains in the respiratory passages, facilitating adequate movement of air. d. Suctioning assists with the opening of the glottis, creating negative intrathoracic pressure.

c. Suctioning removes fluid that remains in the respiratory passages, facilitating adequate movement of air. text