Ch 18 PrepU: Nursing Care of a Family with a Newborn

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns?

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.

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?

"It is a normal skin finding in a newborn." 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. This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection.

A nurse is assessing the congenital reflexes of a newborn. The newborn's parent is watching the nurse and asks, "Why are you testing these things?" Which response by the nurse is appropriate?

"It is a way for us to check your newborn's brain and nerve function." The presence and strength of a reflex is an important indication of neurologic development and function. A reflex is an involuntary muscular response to a sensory stimulus. It is built into the nervous system and does not need the intervention of conscious thought to take effect. Reflex testing does not provide information about muscle strength, joints, or the need for exercises.

A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate?

"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon.

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." Thermoregulation is difficult for newborns due to their inability to produce heat through muscle movement or shivering. They must rely on metabolizing brown fat. Placing a hat on the newborn can assist with thermoregulation. Newborns less than 8 lb (3630 g) still have brown fat. Windows can be problematic due to the potential for convective heat loss. Covering the newborn with heavy blankets is not recommended, because this can place the newborn at risk for sudden infant death syndrome (SIDS).

A woman who gave birth 23 hours ago asks the nurse about what causes the holes in the newborn's heart to close. What is the best response by the nurse?

"The pressure in the atrium of the heart and the chest cause the holes to close." The nurse will educate the parent that the pressure changes in the lungs and atrium (left greater than right after birth) as well as the pressure changes in the chest (pressure drops after birth) are the reasons the shunts or holes in the heart close. The nurse will address the parent's questions and not defer to the medical provider unless the topic was unable to be addressed by the nurse (diagnostic test results etc). The holes direct blood to the lungs, not away from the lungs. The nurse would not give information that does not address the question asked, such as indicating that they do close (but not offering an explanation or restating the question).

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.

A nurse is teaching a new mother about how newborns regulate their temperature. As part of the teaching, the nurse explains brown fat. Which information would the nurse include? Select all that apply.

-brown fat is brown and rich in blood vessels and nerve endings -the newborn keeps itself warm by oxidizing brown fat in response to exposure to the cold -only mature newborns have brown fat -the most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals

The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply.

-give hep B immune globulin -obtain consent from mother -administer hep b vaccination -bathe the newborn thoroughly

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

One minute after birth, the neonate's heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate? 444

4 The Apgar score is a means of quickly assessing the success of the newborn's transition to extrauterine life. Five parameters determine the total Apgar score: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each factor receives a score of 0, 1 or 2 points for a maximum score of 10. Scores of 7 to 10 at five minutes are indicative of a healthy baby who is adapting well to the extrauterine environment. A heart rate of 98 bpm would be 1 point; slow and irregular respirations would be 1 point; arms flexed and hips extended would be 1 point; no grimacing would be 0 points; and acrocyanotic hands and feet would be 1 point, which would give a total of 4 (1+1+1+0+1=4)

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

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?

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. 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. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract.

A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply.

An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client?

Apply petroleum gauze to the penis with each diaper change. When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.

A newborn infant at 36 hours of age is jaundiced. The mother is breastfeeding. What intervention is appropriate to increase the excretion of bilirubin?

Bilirubin is excreted in the urine and feces. Encouraging the mother to breastfeed at least every two to three hours will increase the waste and help decrease the bilirubin level. Stopping breastfeeding and administering glucose water for 24 hours would not be appropriate for the mother. Restricting feedings and giving glucose water every 4 to 6 hours is not an appropriate nursing intervention for an infant showing signs of jaundice. Keeping light away from the baby's skin does not help to clear jaundice; it could only make it worse.

The nurse is performing an assessment on a neonate. Which assessment finding should the nurse prioritize as suggestive of hypothermia?

Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia.

The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?

Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. An example of this is when the infant is placed on a cold scale. Heat loss by convection happens when air currents blow over the newborn's body. An example of this is when the infant is left in a draft of cool air. Evaporative heat loss happens when the newborn's skin is wet. Heat loss also occurs by radiation to a cold object that is close to but not touching the newborn.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

The parent of a newborn notices swelling across the top of the newborn's head and is concerned. The parent states, "This looks painful. What can be done?" The nurse is correct to suggest which action?

Continued assessment but no treatment needed as it will resolve on its own Caput succedaneum is swelling that occurs typically across the presenting part of the head and often crosses a suture line. This occurs in cephalic births and is gradually absorbed and disappears without treatment. There is no need to place a cool compress, place the newborn in an upright position, or notify the health care provider of this condition.

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. An example of convection-related heat loss would be a cool breeze that flows over the newborn. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment. Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Evaporation involves the loss of heat when a liquid is converted to a vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Drying newborns immediately after birth with warmed blankets and placing a cap on their head will help to prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling. Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps to prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

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?

Feeding the infant more formula whenever she begins to fuss 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.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?

Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel (fontanelle). The fontanel (fontanelle) should not be bulging under any circumstance in a newborn.

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents?

Holding and comforting the newborn will not cause the infant to become spoiled. Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

A nurse in a hospital completes a newborn assessment 5 minutes after birth.

Identifying expected and unexpected findings of a newborn is essential. Given the immaturity of systems and trying to adjust to extrauterine life, newborns can deteriorate quickly if problems are not identified and interventions are not implemented promptly. An average APGAR score is 7 to 10, indicating little or no difficulty adjusting to extrauterine life. An APGAR score of 6, 5 minutes after birth is not a normal finding and indicates moderate difficulty adjusting to extrauterine life. A glucose level for a newborn from birth to 2 years should be 60 to 110 mg/dl (3.3 to 5.6 mmol/l). A glucose level of 40 mg/dl is too low; the newborn would most likely show signs of hypoglycemia. A temperature of 97.88°F (36.8°C) is within normal limits for a newborn. The presence of a positive Babinski reflex is normal in newborns up to 1 year of age. Bilirubin levels are expected to be elevated at birth due to immature liver function. For the first 24 hours of life, bilirubin may be from 2 to 6 mg/dl (34.2 to 102.6 mcmol/l). A bilirubin level of 3 mg/dl (51.3 mcmol/l) is within normal limits. The presence of acrocyanosis, peripheral cyanosis around the mouth and extremities, is a normal newborn finding. The presence of vernix caseosa is a normal finding at birth. Vernix caseosa is a white, creamy film covering the skin.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply.

Newborns whose mothers have a positive HBsAg must receive a hepatitis B immunization as well as hepatitis B immune globulin for the prevention of hepatitis B in the newborn. IVIG is not specific for hepatitis B prevention. Hepatitis A vaccination will not prevent hepatitis B in the newborn.

A nurse is providing care to four breastfed newborns who are being monitored for hyperbilirubinemia. When assessing each newborn's indirect bilirubin level, the nurse would notify the health care provider about which newborn?

Neworn D: 48-hour-old newborn with bilirubin level of 14 mg/dl (239.46 µmol/l) There is no set level at which indirect serum bilirubin requires treatment because other factors, such as age, maturity, and breastfeeding status, affect this determination. However, if the level rises to more than 10 to 12 mg/dl (171.04 to 205.25 µmol/l), treatment is usually considered. Therefore, because Newborn D has a level of 14 mg/dl (239.46 µmol/l), treatment is most likely. Newborn C's level is at the lower end of this range, so treatment may or may not be initiated. Newborns A and B have levels below the range cited.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?

Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age.

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?

Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

A nurse is preparing to administer erythromycin ointment to a 1-hour-old newborn. What will the nurse do first?

Review the health care provider's order.

In which newborn should the nurse suspect hypoglycemia?

Signs of hypoglycemia include jitteriness, irritability, lethargy, respiratory distress, and a high-pitched cry.

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?

The first few breaths greatly increase the oxygen content of circulating blood. This chemical change (i.e., higher oxygen content of the blood) contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. A drop in the pressure results in a reversal of pressures in the right and left atria, causing the foramen ovale to close, which redirects blood to the lungs. A drop in blood pressure and higher oxygen levels at the respiratory centers of the brain do not result in the closure of the foramen ovale.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

A female 1-day-old newborn's temperature is 97.1℉ (36.2℃) in an open crib and the newborn has been in the mother's room for several hours. What action should the nurse take? Select all that apply.

The newborn's temperature is low and she needs to be warmed up. Placing a cap on her head and wrapping her in a blanket helps the newborn conserve body heat. Determining the maternal room temperature is important to ensure that the newborn was not chilled while out with the mother, and helps determine the cause of the hypothermia. Lastly, placing the crib away from walls and drafts will help prevent heat loss and maintain a thermoneutral environment. Increasing the nursery temperature is not a good idea since this may overheat this newborn as well as other babies in the nursery.

The parent of a newborn tells the nurse the newborn seems "fussy and aggravated" when being cared for. What action by the nurse is most appropriate at this time?

The nurse will assess the newborn's glucose level. Irritability is a sign of hypoglycemia. The nurse would always verify the newborn's identification bracelet with the mother's identification, regardless of the parent's statement. The health care provider would need to be notified if the newborn's glucose is too high or too low, but the nurse should obtain the glucose level first. The oxygen saturation level is vital to assess for all newborns, but this action would not be a priority assessment based on the parent's comments.

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?

The stool of formula-fed newborns varies depending on the type of formula ingested, but it typically is yellow, yellow-green, or greenish, loose, pasty, or formed with an unpleasant odor. Greenish-black tarry stool denotes meconium. Thin, yellowish, seedy brown stool characterizes the transitional stool that occurs after meconium. Sour-smelling yellowish-gold stool that is loose and stringy to pasty in consistency is typical of a breastfed newborn stool.

What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? normal findings

These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6°F (36.5°C to 37.5°C). Blood pressure should be 60-80/40-45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

A neonate born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this neonate?

To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Neonates are screened even in the absence of symptoms; this is done before feedings to obtain a preprandial measure.

A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect?

Vitamin K injections are given to ensure that neonates do not hemorrhage while their immature liver increases production of clotting factors.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation. Following circumcision, the nurse will monitor the newborn for bleeding, voiding and pain. A spot larger than the size of a quarter, not a dime, is reported to the physician. The penis is washed in warm water with no soap with each void. Diapers are left loose so as to not press on the newly circumcised penis. Talc powder is never used when changing diapers. The newborn is given 12 hours to void before the nurse becomes concerned.

Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications?

Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm For a term infant, expected weight is 2500 to 4000 g; length is 19 to 21 inches; head circumference is 33 to 35 cm; and chest circumference is 30.5 to 33 cm.

When assessing the newborn's umbilical cord, what should the nurse expect to find?

When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize?

explain this is normal Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. There is no need to call the RN or health care provider, change and bathe the infant, or check the vital signs.

The Apgar score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an Apgar score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as:

jaundice Hyperbilirubinemia is caused by the accumulation of excess bilirubin in blood serum. In the average newborn, the skin and sclera of the eyes begin to appear noticeably yellow on the second or third day of life as a result of a breakdown of fetal red blood cells (called physiologic jaundice). This happens because as the high red blood cell count built up in utero is being reduced, heme and globin are released. Cyanosis is a condition of decreased oxygenation that results in the skin having a blue hue. Pallor, or a pale appearance to skin, occurs as a result of anemia, or lack of red blood cells due to low iron stores, blood loss, poor circulation, or internal bleeding. The harlequin sign is when one side of the body appears red and the other pale, due to immature blood circulation.

A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next?

look at the woman's hospital identification badge Each member of the hospital staff should have an identification badge clearly displayed. The nursery nurse should look at the badge of the woman who is offering to take Mrs. Smith's baby to her as this is the only way to ensure the nurse is allowing an appropriate person to transport the baby. Education and watchful vigilance are the keys to preventing infant abductions. Each facility that cares for newborns should have specific policies and procedures in place that address this problem. The nurse should review these policies and know the protocols for the facility in which the nurse will be working.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior. From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first?

respiratory distress It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot The calcaneus is the bone of the heel. A heel stick should not be done on the flat part of the foot or heel, but instead on the lateral aspect of the foot, where the fat pads are.

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?

will decrease risk of bleeding immediately after birth 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.

The nurse reviews the newborn's morning laboratory levels and notes a bilirubin level of 5.8 mg/dl (99.20 µmol/l). What will the nurse expect to assess in the newborn?

yellow-tinted skin on the head and face When the newborn's serum bilirubin level is 4 to 6 mg/dl (68.42 to 102.62 µmol/l) or higher, the newborn will exhibit jaundice. The appearance of jaundice (yellowing) will start on the head and face and move down the trunk. The stools of the newborn will not be yellow due to jaundice. The liver is overwhelmed by the large volume of red blood cells but is not physically enlarged.