Chapter 18 prep U

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "No, it is the tonic neck reflex. It signifies handedness."

Correct response: "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." Explanation: The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? "Change the newborn's diaper every four hours while awake." "Place the newborn on the back to sleep and stomach to play." "Newborns can sleep on a couch to allow constant visual monitoring." "You need to give your newborn a bath everyday."

Correct response: "Place the newborn on the back to sleep and stomach to play." Explanation: Newborns should always be placed on their backs to sleep to reduce the risk for SIDS and on their stomach a few times a day to develop neck muscles. Caregivers should change the newborn's diaper when it is soiled, not at timed intervals. Newborns should never be left unattended on high surfaces to prevent injury from falls. Bathing a newborn daily is not recommended as it may dry the skin.

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."

Correct response: "We will fold down the front of her diaper under the umbilical cord until it falls off." Explanation: 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.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? When the infant is 48 hours old 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents Just before discharge home

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

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 1 to 2. 5 to 9. 7 to 10. 12 to 15.

Correct response: 7 to 10. Explanation: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? Ask the woman to bring the infant back when the doctor finishes the examination. Call the nursery to confirm the doctor does indeed need this infant at this time. Ask to see the woman' hospital identification badge. Ask how long the infant will be gone since her next feeding is in 30 minutes.

Correct response: Ask to see the woman' hospital identification badge. Explanation: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

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.

Correct response: Cover the glans generously with petroleum jelly. Explanation: 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.

Correct response: Dry the newborn and place it skin-to-skin on mother. Explanation: 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.

Correct response: Dry the newborn and place it skin-to-skin on mother. Explanation: 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.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? Epstein pearls milia stork bites Mongolian spots

Correct response: Epstein pearls Explanation: Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein pearls.

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.

Correct response: Inspect the clamp to insure that it is tightly closed and applied correctly. Explanation: 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 woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate? It is a normal skin finding in a newborn. It is a sign of a group beta-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.

Correct response: It is a normal skin finding in a newborn. Explanation: This rash is most likely is erythema toxicum, also known as newborn rash.

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.

Correct response: Suction the mouth and nose. Explanation: 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.

A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used. 1Transfer the newborn to a preheated radiant warmer. 2Dry the newborn. 3Clear the airway. 4Stimulate the newborn by rubbing the back. 5Check the heart rate.

Correct response: Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate. Explanation: Commonly the first step in a nursing intervention cascade is assessment. However, the nurse already has assessed that the newborn is term, is not crying, and has decreased tone that would require intervention. The first step is to warm the newborn and then to decrease any further loss of heat through evaporation by drying the newborn. The airway should be cleared before the newborn is stimulated to avoid aspiration. The nurse would then check the heart rate to see if further resuscitation efforts are necessary.

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.

Correct response: Use the sealed and chilled milk within 24 hours. Explanation: 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.

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as: potential for respiratory distress. poor oxygenation. cold stress. acrocyanosis.

Correct response: acrocyanosis. Explanation: Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.

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

Correct response: blood sugar Explanation: 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).

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.

Correct response: harlequin sign. Explanation: 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.