Chapter 18: Nursing Management of the Newborn

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? -Inspect the clamp to insure that it is tightly closed and applied correctly. -Clean the cord with soap and water, as oozing of blood is a common finding. -Remove the clamp and replace with another one just above the old one. -Notify the doctor to come suture the site of the bleeding.

Inspect the clamp to insure that it is tightly closed and applied correctly. Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.

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? -"This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." -"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." -"The teeth will fall out within the first month, so don't worry about them." -"The teeth will fall out when the newborn's baby teeth come in so this is a blessing."

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." 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.

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

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.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? -The infant may sleep through the night around 2 months of age. -Caregivers need to sleep while the baby is sleeping. -Newborns usually sleep for 16 or more hours each day. -Place the infant on the back when sleeping.

Place the infant on the back when sleeping. It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? -Help the mother provide skin-to-skin (kangaroo) care. -Place a second stockinette on the baby's head. -Administer a warm bath with temperature slightly higher than usual. -Place the infant under a radiant warmer.

Help the mother provide skin-to-skin (kangaroo) care. The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? -Wipe the tongue off vigorously to remove the white patches. -Rinse the tongue off with sterile water and a cotton swab. -Since it looks like a milk curd, no action is needed. -Report the finding to the pediatrician.

Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

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? -Apgar score -blood sugar -heart rate -temperature

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).

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? -hearing -vision -genetic-linked -skeletal malformation

hearing Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? -two or three times per week -once a week -once a day -every other day

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? -"Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." -"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." -"Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." -This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, does not help prevent ophthalmia neonatorum, or strengthen the immune system.

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective? -"We will vigorously rub our baby's back as we play some music." -"We will place our baby on the belly on a blanket on the floor." -"We will turn the mobile on that's hanging on our baby's crib." -"We will hold feedings until our baby stops crying."

"We will turn the mobile on that's hanging on our baby's crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? -"We'll turn on the mobile that's hanging above his head in his crib." -"We'll lightly rub his back as we talk to him softly." -"We'll swaddle him snuggly to make him feel secure." -"We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full." Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program? -Caregivers can demonstrate competency in caring for the infant and ask questions. -The nurse can discuss parenting conflicts with the caregivers to determine which style is best. -Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. -The nurse will complete any procedures the infant was not able to have performed while in the hospital.

Caregivers can demonstrate competency in caring for the infant and ask questions. Home visitation programs provide caregivers with opportunities to do return demonstrations of care, ask questions of a professional, and be reassured of their ability to care for their infant. The visiting nurses do not take over care of the infant or serve as an arbitrator for disagreements. All necessary procedures will be completed in the hospital prior to discharge.

Which action will the nurse avoid when performing basic care for a newborn male? -Inspecting the genital area for irritated skin -Palpating if testes are descended into the scrotal sac -Determining the location of the urethral opening -Retracting the foreskin over the glans to assess for secretions

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 woman has just given birth vaginally to a newborn. Which action will the nurse do first? -Apply identification bracelets. -Suction the mouth and nose. -Assess an apical heart rate. -Determine the rectal temperature.

Suction the mouth and nose. The first priority is to ensure a patent airway by suctioning the newborn's mouth and nose. Before leaving the birthing area, newborn identification procedures are completed, including applying the identification bracelet and possibly footprinting, depending on the agency's policy. An apical heart rate and temperature are checked soon after birth, but do not take priority over ensuring a patent airway.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? -Perform a 3-minute surgical-type scrub. -Wear clean gloves. -Use infection transmission precautions. -Clean hands with a betadine scrub.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

Assessment of a newborn reveals microcephaly. The nurse develops a teaching plan for the parents about the need for follow-up care based on the understanding that the newborn is at risk for developing which complication(s)? Select all that apply. -epilepsy -cerebral palsy -hearing disorders -hydrocephalus -achondroplasia

epilepsy cerebral palsy hearing disorders Infants with microcephaly are also noted to have additional complications such as epilepsy, cerebral palsy, intellectual disability, and ophthalmologic and hearing disorders. Hydrocephalus and achondroplasia are more commonly seen with macrocephaly.

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." -"It is a sign of a group B streptococcus skin infection. " -"It is an indication that the woman has mistreated her newborn." -"It is a self-limiting virus that does not require treatment."

"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.

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

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

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? -Swaddle the infant and place in the bassinet. -Complete a full head-to-toe assessment. -Assess the newborn's glucose level. -Dry the newborn and place it skin-to-skin on mother.

Dry the newborn and place it skin-to-skin on mother. Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? -Conductive -Convective -Evaporative -Radiating

Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. -Provide warm water to drink. -Provide oxygen supplementation. -Massage the newborn's back. -Ensure the newborn's warmth. -Observe respiratory status frequently.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently. The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

A nurse is preparing to administer erythromycin ointment to a 1-hour-old newborn. What will the nurse do first? -Administer the medication in each eye. -Review the health care provider's order. -Apply gloves and obtain the medication. -Explain the procedure to the caregivers.

Review the health care provider's order. Prior to administering the erythromycin ointment, the nurse will review the order. The nurse would then explain the procedure to the caregivers, apply gloves, and administer the medication in both eyes.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? -Use the sealed and chilled milk within 24 hours. -Use any frozen milk within 6 months of obtaining it. -Use microwave ovens to warm the chilled milk. -Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

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. -Warmer bed -Glucose water -Suction equipment -Identification bands -Ophthalmoscope

Warmer bed Suction equipment Identification bands 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.

On an Apgar evaluation, how is reflex irritability tested? -raising the infant's head and letting it fall back -flicking the soles of the feet and observing the response -dorsiflexing a foot against pressure resistance -tightly flexing the infant's trunk and then releasing it

flicking the soles of the feet and observing the response Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participants correctly choose which items will be on matching identification bracelets? -hospital number, attending care provider, and father's name -blood type and date and time of birth -mother's name, infant's blood type, and date and time of birth -newborn's sex and date and time of birth

newborn's sex and date and time of birth Information included on the bands is the mother's name, hospital number, care provider's name, newborn's sex, and date and time of birth. The father's name and infant's blood type would not be included on these bracelets, which are put on at the time of birth.

The Apgar score is based on which 5 parameters? -heart rate, muscle tone, reflex irritability, respiratory effort, and color -heart rate, breaths per minute, irritability, reflexes, and color -heart rate, respiratory effort, temperature, tone, and color -heart rate, breaths per minute, irritability, tone, and color

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.

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse (PMI)? -at the third intercostal space adjacent to the midclavicular line -at the midsternum, just below the suprasternal notch -lateral to the midclavicular line at the fourth intercostal space -at the fifth intercostal space at the right midclavicular line

lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize? -Notify the health care provider immediately. -Assess the newborn for signs of respiratory distress. -Reassure the parents that this is an expected pattern. -Tell the parents not to worry since his color is fine.

Assess the newborn for signs of respiratory distress. Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? -Expose the newborn's bottom to air several times a day. -Use only baby wipes to cleanse the perianal area. -Use products such as talcum powder with each diaper change. -Place the newborn's buttocks in warm water after each void or stool.

Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

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? -This is an abnormal finding and needs to be reported immediately. -If the fontanel feels full, then this is normal. -This finding is normal if the pulsation can also be palpated in the posterior fontanel. -It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.

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 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. -Harlequin sign noted on left upper outer thigh. -Mottling noted on left upper outer thigh. -Birth trauma noted on left upper outer thigh.

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.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action? -Wrapping the newborn in a towel and placing it on the mother's abdomen. -Allowing the mother to cut the cord of the newborn. -Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. -Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: -harlequin sign. -stork bites. -Mongolian spots. -erythema toxic.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

The Ballard scoring system evaluates newborns on which two factors? -physical maturity and neuromuscular maturity -skin maturity and reflex maturity -tone maturity and extremities maturity -body maturity and cranial nerve maturity

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. -temperature of 38.3° C (101° F) or higher -refuse feeding -abdominal distention -general fussiness -approximately eight wet diapers a day

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

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? -"He has normal male genitalia." -"His testicles have not descended into the scrotal sac." -"The opening of his urethra in located on the under surface of the tip of the penis." -"He has fluid in the scrotal sac."

"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 nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? -"We will apply a moisture barrier cream with every diaper change to prevent diaper rash." -"We should clean the skin with soap and water after each bowel movement." -"We will fold down the front of her diaper under the umbilical cord until it falls off." -"It is best practice to change the diaper every 2 to 4 hours, even during the night."

"We will fold down the front of her diaper under the umbilical cord until it falls off." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply. -If a newborn becomes lethargic or sleepy, draw a heel stick blood glucose. -Offer glucose feedings to all newborns at 1 hour of age. -Encourage breastfeeding mothers to nurse immediately after delivery. -Keep the newborns warm in the nursery and covered with a blanket. -Initiate early feedings for all bottle-fed newborns.

-Encourage breastfeeding mothers to nurse immediately after delivery. -Keep the newborns warm in the nursery and covered with a blanket. -Initiate early feedings for all bottle-fed newborns. To prevent injury from hypoglycemia, prevention of hypoglycemia is critical. Breastfeeding mothers are encouraged to begin feedings early and continue on a frequent basis. Bottle-fed newborns require early feedings as well. Thermoregulation can also help maintain a newborn's blood glucose. Doing a heel stick blood glucose is a good idea for a lethargic newborn but will not prevent hypoglycemia from occurring. Glucose water feedings are no longer recommended.

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? -Complete the hearing test. -Provide hepatitis B vaccination. -Administer aquamephyton. -Perform the newborn screening.

Administer aquamephyton. Aquamephyton, or vitamin K, is used to promote blood clotting in the newborn and is priority to administer to the newborn. The hearing test, hepatitis B vaccine, and newborn screening should all be completed prior to discharge.

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? -Recommend that the mother pump her breast milk and measure it before feeding. -Breastfeed the infant every 2 to 4 hours on demand. -Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. -Add cereal to the newborn's feedings twice a day.

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

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? -Administer an oral dose of vitamin K to the newborn. -Assume that the parents refused this medication for their infant. -Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. -Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? -Check blood glucose. -Place child in a radiant warmer. -Assess for pain source. -Assess the baby's temperature.

Check blood glucose. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? -Send a family member to accompany the infant when leaving the room. -Check the name on the baby's identification bracelet. -Provide a list of approved visitors who came spend time with the infant. -Check the identification badge of any health care worker before releasing baby from room.

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? -Inform the mother of the results of the hearing test completed on the newborn. -Compare the identification bracelets prior to leaving the newborn with the mother. -Explain the procedure completed on the newborn to the mother. -Determine if it is time for the mother to breastfeed the newborn and assist as needed.

Compare the identification bracelets prior to leaving the newborn with the mother. Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? -Soak the penis daily in warm water. -Cover the glans generously with petroleum jelly. -Cleanse the glans daily with alcohol. -Notify the primary care provider if it appears red and sore.

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

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

Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. -Providing the first bath -Changing a diaper -Performing a heel stick Accucheck -Feeding the newborn a bottle -Taking the newborn's crib to the mother's room

Providing the first bath Changing a diaper Performing a heel stick Accucheck Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? -Rocking and singing to her infant. -Use of mobiles above the crib. -Swaddling the infant -Holding and cuddling the infant

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

A nurse is preparing to administer Vitamin K to a newborn. The nurse would administer the drug: -orally. -subcutaneously. -intramuscularly. -intravenously.

intramuscularly. The American Academy of Pediatrics recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a one month period. It is not given subcutaneously or intravenously.