Chapter 13: Nursing Care During Newborn Transition

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).

The mother of a 1-day-old newborn calls the nurse alarmed and asks the nurse to hurry to her room because there is something wrong with her baby. The nurse arrives to find the newborn lying on his crib on his side, awake and crying with one side of his body a dark red color and the other side of his body is pale. What would the nurse tell this mother?

"This is a harlequin sign and is a normal finding in newborns. It usually occurs when the infant is crying or when he is lying on his side." A common variant in skin color is the harlequin sign, where the blood vessels on one side of the body dilate (causing a dark appearance) and the blood vessels on the other side constrict (causing pallor). This is normal and requires no intervention or notification of the doctor. Telling a mother that the nurse has never seen this finding does not reassure her, although she is told he is OK.

The nurse performs a quick assessment of an infant who is now 5 minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize?

6; repeat Apgar scoring in 10 minutes The Apgar scoring system evaluates the heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Each factor receive a score of 0 to 2 which are added up to obtain the Apgar score. These scores are obtained at 1 minute and 5 minutes after birth. A score of 7 to 10 at 5 minutes is indicative of a healthy baby who is adapting well to the extrauterine environment. Scores of 4 to 6 at 5 minutes indicate the newborn is having some difficulty. Scores of 0 to 3 indicate the newborn is experiencing extreme difficulties and require immediate intervention. An infant with a score of less than 7 should continue to be reevaluated every 5 minutes until the score comes up to 7. A heart rate of 110 is given a score of "2"; a weak cry "1"; acrocyanosis "1"; extremities in partial flexion "1"; and grimacing reflexes "1" gives a total Apgar of 5 (2+1+1+1+1=6).

Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant?

Abrupt temperature change upon delivery, causing a cry Respiratory adaptation following birth is seen in an infant that responds with a strong cry following thermal changes, such as those the newborn experiences going from the warm uterus to the cold outside air. The first breath should occur within the first few moments after birth, not after 3 minutes. The rapid decrease in oxygen and increase in the CO2 levels, not the reverse, serves as stimulation for respirations. Tachypnea following a cesarean birth does not demonstrate respiratory adaptation but may indicate fluid retention and complications.

Which findings by a nurse would be considered abnormal when examining the eyes of a newborn? Select all that apply.

Absent red reflex Blue-tinged sclera The normal response is a red reflection from the retina, and absence of a red reflex is associated with congenital cataracts. The sclera should be white, not blue. All other findings are normal variants for an eye exam.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?

Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply.

Fingernails are present and extend to the end of the fingers. Pinnae are flexible with rapid recoil. Creases on the feet cover 2/3 of the bottom of the feet. Full-term infants will have fingernails, a pinna with cartilage with rapid recoil when bent down, and creases over the upper 2/3 of the sole of the foot. The labia majora will be more prominent in full-term infants and their posture is flexed.

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek. Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply.

Jitteriness Low body temperature Irritability A newborn who is experiencing hypoglycemia will exhibit several signs that need to be recognized. They include jitteriness, irritability, listlessness, low body temperature and poor feeding. The newborn will not be diaphoretic.

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse?

Notify the charge nurse, because it represents a possible complication, and document the finding. The base of the cord should be dry without redness or drainage, and the umbilical clamp should be fastened securely. The white drainage and redness are potential signs of an infection and would need to be reported immediately to the RN by the LPN. Antibiotics may or may not be necessary, however.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. If a nurse is concerned that the nostrils are patent in a newborn, the nurse will occlude the nares one at a time to see if the newborn can breath easily. The nurse would never place something like a swab into the nares to check patency due to potential trauma. Nasal flaring is an abnormal finding and indicates respiratory distress, not ease of breathing. Passing an NG tube is traumatic to the newborn and is not needed in most cases.

During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn?

Quiet alert state In the quiet alert state, the newborn's eyes are open and the infant is attentive to people and things occurring in close proximity to them. This is an ideal time for parents to interact with the infant.

Which action will the nurse avoid when performing basic care for a newborn male?

Retracting the foreskin over the glans to assess for secretions The foreskin in male newborns does not normally retract and should not be forced. The nurse will inspect the genital area for irritated skin to prevent and/or treat possible skin irritations. The nurse will palpate the testes to determine if the newborn has cryptorchidism. It is important to verify that the urethral opening is at the tip of the glans and not on the dorsal or ventral sides as these would need intervention. This can be accomplished without overmanipulating the foreskin.

A nurse is doing an admission assessment on a female infant born to a primipara. Which findings would warrant notification of the physician? Select all that apply.

Scaphoid abdomen Head circumference of 38 cm A heart rate from 100 to 160 is considered a normal range for a newborn. The newborn will also exhibit an episodic breathing pattern, where the respirations are irregular with small pauses interspersed with rapid respirations. Overlapping cranial sutures are also normal, especially as this is the mother's first baby. The two abnormal findings are the scaphoid abdomen, which should be rounded or protuberant, and the head circumference (HC) of 38 cm. A normal HC is 33 to 35.5 cm.

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria?

The bilirubin peaked between days 3 and 5 after birth. Physiologic jaundice involves the liver's inability to break down the bilirubin as fast as it is being produced due to the immaturity of the liver. The criteria for physiologic jaundice is that the jaundice occurs after 24 hours of age, it peaks between days 3 and 5 and does not rise more than 5 mg/dl per day Conjugated bilirubin is the water-soluble version of bilirubin and is excreted in feces; it should always be lower than the unconjugated bilirubin.

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?

The breakdown of RBCs release bilirubin, which the liver cannot excrete. 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. Vitamin K levels have no effect on bilirubin levels. The immaturity of the GI tract does not cause the bilirubin to increase and feedings do not directly affect bilirubin levels.

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the infant's blood?

The foramen ovale closes, preventing blood exchange from right to left in the heart. As the infant takes its first breath, the pressure gradient in the heart reverses from the intrauterine state. The higher pressure switches to the left side of the heart, which closes the foramen ovale, sending blood to the lungs instead of across the opening. The ductus venosus and the ductus arteriosus both close and become ligaments and the umbilical vein atrophies after the cord is cut.

The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?

The rooting reflex was tested incorrectly. Gently stroking the newborn's cheek brings out the rooting reflex. The newborn would demonstrate this reflex by turning toward the touch with an open mouth. This infant demonstrates a positive suck reflex but does not display the rooting reflex because the test was performed incorrectly.

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

convection 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.

A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.

"I understand your concern because as many as 50% of babies can develop jaundice." 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 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 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.

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"The opening of his urethra in located on the under surface of the tip of the penis." The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern?

"The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." The normal weight loss of a newborn is 5% to10% of their birth weight, which means an average of 6 to 10 oz (168 to 280 g). This newborn's weight loss falls within the normal range. There is no need to increase the feeding frequency or notify the doctor and there is no indication of any underlying health problem.

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response?

"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.

The nurse is conducting a newborn assessment and notes the head circumference is 35 cm. What is the largest measurement that the nurse will predict for the chest circumference in this newborn?

33 The chest circumference in a term newborn is usually 2 to 3 cm smaller than the head circumference. 35 cm - 3 cm = 32 cm 35 cm - 2 cm = 33 cm Thus, the larger chest circumference is 33 cm.

A newborn is born and, 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?

6 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, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.

In which newborn should the nurse suspect hypoglycemia?

A jittery, irritable newborn with a high-pitched cry Signs of hypoglycemia include jitteriness, irritability, lethargy, respiratory distress, and a high-pitched cry.

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11. The newborn has physiologic jaundice, which is related to decreased bilirubin conjugation. Newborns have relatively immature livers and cannot conjugate (break down) bilirubin as fast as needed. Bilirubin overproduction is responsible for causing jaundice. A serum bilirubin is the best way to determine whether the jaundice is improving. The other listed methods will not address the needed information.

A nurse is conducting an in-service education program for a group of nurses working in the newborn nursery. The nurse has explained the events that occur as fetal circulation transitions to newborn circulation. The nurse determines the session is successful after the participants put the chain of events in which order? All options must be used.

Birth occurs. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes. Immediately after birth, pulmonary vascular resistance decreases, and pulmonary blood flow increases. This happens secondary to an increase in PO2 as a result of the first breath and umbilical cord clamping. An increase in left atrial pressure causes the foramen ovale to close. This leads to a continued increase in systemic blood pressure with continued increase of blood flow to the lungs. The ductus arteriosus closes a few hours after birth.

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?

Blood Pressure The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

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. Brown fat, a special tissue found in mature newborns, helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. The greatest amounts of brown fat are found in the intrascapular region, the thorax, and behind the kidneys and makes up 2% to 6% of a term newborn's body weight. It is brown in color and rich in blood vessels and nerve endings. The newborn will oxidize the brown fat in response to exposure to the cold and help warm up their body.

A newborn's ears are lined up below a line from the inner to outer canthus of the eye, extending past the ear. What other possible findings should the nurse be aware of in this client? Select all that apply.

Cognitive impairment Internal organ defects A newborn noted to have low-set ears often has associated cognitive impairments or internal organ defects. Numerous genetic disorders have low-set ears as one of the characteristics of the syndrome. Deafness, cleft palate and hydrocephalus are not associated with low-set ears.

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?

Conduction 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.

A newborn is placed in an open crib in the newborn nursery, which is located near the doorway to the hall. What type of heat loss would this infant experience?

Convective Convective heat loss occurs when air currents blow across the infant's body, causing it to chill. By placing the infant near a doorway, the infant will be exposed to drafts. Conductive heat loss occurs with direct contact with a cold surface. Evaporative heat loss occurs with moisture evaporating from the body. Radiant heat loss occurs with being close to a cold object but not touching it.

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?

Creases on two-thirds of the foot As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take?

Document the data. The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly. Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

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.

The nurse is conducting a prenatal class for new parents illustrating the various functions their newborn should be able to perform. The nurse determines additional teaching is necessary when the group chooses which action as one they will expect their newborn to exhibit?

In the first few hours after birth, newborns do not typically demonstrate a response to close visual stimuli. Newborn behaviors are predictable after birth. They enter an initial phase of reactivity followed by a longer period of decreased responsiveness and then a second period of reactivity. They respond to visual and auditory stimuli.

Which of the following would lead you to suspect that a newborn has developmental hip dysplasia?

Inability of the right hip to abduct Newborns whose acetabulums are shallow cannot abduct their hip joint.

A nurse is explaining the Apgar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply.

It is done at 1 and 5 minutes after birth. The baby is considered vigorous if the 5-minute score is above 7. The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation. At 1 minute and 5 minutes after birth, newborns are observed and rated according to an Apgar score, an assessment scale which helps evaluate the newborns transition from intrauterine to extrauterine life. The factors evaluated include the heart rate, respiratory effort, muscle tone, reflex irritability, and color of the infant; each of which are rated 0, 1, or 2. These numbers are then added up to give the total score. A score of 7 or better is considered vigorous and the infant is adjusting well. A score of 4 to 6 indicates the infant is having difficulties and should continue to be reevaluated every 5 minutes until a score of 7 is obtained. A score of 0 to 3 indicates serious danger and requires further evaluation. There is a high correlation between low 5-minute Apgar scores and neurologic illness The Apgar score is NOT used to guide newborn resuscitation.

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?

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. 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. The fontanel should not be bulging under any circumstance in a newborn.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?

Jitteriness and irritability Infants born to women who are morbidly obese are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.

Lanugo on the back Milia Acrocyanosis A full-term newborn may have thin patches of lanugo over his back, shoulders or arms. He may also have milia, which appear as white papules on the face. Acrocyanosis at 3 hours of age is also a normal finding. However, this should resolve by 24 to 48 hours of age. A newborn at 3 hours of age should never have jaundice. Vernix on the abdomen and lower extremities is seen in preterm infants, not full-term ones.

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?

Mongolian spot noted on left upper outer thigh. A 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 enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize?

Move the infant away from the window. The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed?

No interventions are needed. This will resolve on its own over the next several days. This newborn has a caput succedaneum, which is 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.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?

Perform a heel stick to obtain a blood sample for testing for glucose level. 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.

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. 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 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Place the newborn away from drafts and under a blanket. When a newborn becomes cold stressed, they often develop respiratory distress. The newborn's temperature is low, so the first nursing action is to place the newborn in a warmer environment and cover with a blanket to warm the newborn up. The serum glucose is normal so the newborn does not need additional nutrition. The newborn does not have documented hypoxia, so oxygen is not appropriate. Pillows are never used in newborn's beds due to the risk of suffocation.

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.

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 the newborn has minimal activity or body movement?

Quiet alert A newborn that has its eyes open but is quiet and observing people and things around him is in the quiet alert state. The active alert state is characterized by the newborn having the eyes open but is moving about. The drowsy state shows the newborn whose eyes are open and closing with heavy eyelids and is intermittently fussy. There is no "active attentive" state according the Neonatal Behavioral Assessment Scale.

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?

Taking no action because these are normal findings in a newborn The rate, rhythm, and depth of breathing in a newborn are often irregular. Because these are normal findings, no further action is required by the nurse.

Which of the following is true regarding the newborn's fontanelles?

The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm. The anterior fontanel is diamond shaped and is larger than the posterior fontanel, which is triangular in shape.

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?

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

What chemical change occurs to stimulate respirations in a newborn's brain after birth?

The newborn's pH level falls. Once the umbilical cord is cut, the newborn's lifeline is severed and the oxygen levels fall as the carbon dioxide levels increase, causing the newborn's serum pH to fall, which makes the newborn acidotic. This acidosis, combined with the low oxygen blood levels, stimulates the respiratory center in newborn's brain to begin respirations.

What physical change does not contribute to the impetus for a full-term newborn to begin breathing following birth?

The respiratory center in the brain is stimulated by the noise around the newborn. Once the umbilical cord of a newborn is cut, there is a chemical change that stimulates the respiratory center of the brain caused by a decrease in oxygen and a rise in carbon dioxide levels. The respiratory center is not stimulated by noise surrounding the newborn. A change in environmental temperature and being touched directly for the first time also serve as stimulants for breathing.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch. The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.

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 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.

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding?

This is a cephalohematoma that typically spontaneously resolves without interventions. The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the swelling crosses the suture line, caput succedaneum is suspected. A subarachnoid hemorrhage in a newborn usually results in symptoms such as seizures, apnea, and bradycardia.

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.

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client?

Wrap the infant in a blanket and hand to the mother for bonding. Apgar scores of 7-10 at 5 minutes of age indicate a newborn is adapting well to extrauterine life and can be safely placed with the mother. A 5-minute Apgar score of 4-6 would mean that the newborn might have respiratory distress and need oxygen or requires more vigorous stimulation. Hypothermia can also cause distress and lower the Apgar score.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

a respiratory rate of 15 breaths per minute with nasal flaring Coughing and sneezing are normal reflexes present in the newborn. The respiratory rate of a newborn should be between 30 and 60 breaths per minute. Acrocyanosis can be a normal finding in a newborn and does not indicate respiratory distress. Short periods of apnea that last longer than 15 seconds in the absence of cyanosis can be normal. Nasal flaring is a sign of respiratory distress.

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production. Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother Baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night Baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother Baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first?

baby C Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream (serum levels of 4 to 6 mg/dl [68.4 to 102.6 µmol/L] and greater), can lead to jaundice, a yellow staining of the skin. Only baby C has hyperbilirubinemia. All the vital signs are within normal limits: Heart rate 110 to 160 beats per minute; respiratory rate 30 to 60 breaths per minute; axillary temperature 97.7°F to 98.6°F (36.5°C to 37°C); and blood pressure 60-80/40-45 mm Hg.

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice?

bilirubin hyperexcretion Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirubin conjugation or conversion, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is:

caused by his mother's hormones. Both male and female newborns may have a milky breast discharge from being under the influence of female hormones in utero.

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction 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. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. 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. 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.

The nurse is helping her client to recognize signs of hunger in her newborn. The nurse knows that her client needs additional teaching when she states that which sign is one of the early signs of hunger?

crying The client needs additional teaching if she states crying as an early sign of hunger; it is a relatively late sign of hunger. Restlessness, tense body, lip smacking, and tongue thrusting are all early signs of hunger.

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

evaporation Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. 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. 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. 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.

A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth?

hearing Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Vision is the least mature sense at birth. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn?

hemolysis of erythrocytes As the newborn takes on breathing, the extra erythrocytes are no longer needed and start to break down or hemolyze. This results in extra bilirubin now circulating in the blood stream or hyperbilirubinemia which will lead to jaundice. The heme is used by the liver to create new erythrocytes. This will also result in the decreasing level of hematocrit not increase.

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?

higher oxygen content of the circulating blood 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 preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

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

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

A nurse is developing a plan of care for a newborn to minimize the risk for heat loss. The nurse prioritizes potential interventions based on which mechanism is responsible. Place the interventions listed below in the order the nurse would address them based on the mechanism accounting for the greatest to least amount of heat loss. Use all options.

placing the newborn under a radiant warmer during a procedure using a warmed isolette to transfer a newborn to the nursery drying the newborn after giving the newborn a bath encouraging skin-to-skin contact with the mother The transfer of heat depends on the temperature of the environment, air speed, and water vapor pressure or humidity. Heat exchange between the environment and the newborn involves the same mechanisms as those with any physical object and its environment. Heat can be lost by four mechanisms: radiation which accounts for approximately 39% of heat loss, convection which accounts for about 34% of heat loss, evaporation which accounts for about 24% of heat loss, and conduction which accounts for about 3% of heat loss. Based on the mechanism, the nurse would prioritize placing a newborn under a radiant warmer, using a warmed isolette to transfer the newborn, drying after bathing, and encouraging skin-to-skin contact.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction 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. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

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

two smaller arteries and one larger vein 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.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

respiratory and cardiovascular Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

A nurse is reviewing the history and physical examination findings of a postpartum woman and her female neonate. The neonate was healthy at birth but is now exhibiting signs of jaundice. Which factor(s) would the nurse assess to help identify the neonate suffers from jaundice? Select all that apply.

use of oxytocin during labor maternal gestational diabetes maternal TORCH infection Common risk factors for the development of jaundice include fetal-maternal blood group incompatibility, prematurity, asphyxia at birth, an insufficient intake of milk during breastfeeding, drugs (such as diazepam, oxytocin, sulfisoxazole/erythromycin, and chloramphenicol), maternal gestational diabetes, infrequent feedings, male gender, trauma during birth resulting in cephalohematoma, cutaneous bruising from birth trauma, polycythemia, previous sibling with hyperbilirubinemia, and intrauterine infections such as TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and other organisms).

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth The healthy newborn should pass meconium within 24 hours of life.