Chapter 18

A newborn is 7 minutes old. Her heart rate is 92 bpm, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?

5

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10.

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

Bathe the newborn thoroughly

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment?

Be attentive to the basic needs of the infant and be consistent.

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

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 recommendations would the nurse not make to this mother?

Feeding the infant more formula whenever she begins to fuss

The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record?

Head one fourth of total length

A patient who has just given birth to her first baby asks the nurse for help with breast-feeding. Which nursing diagnosis would be the most appropriate for the patient at this time?

Health-seeking behaviors

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5oF (37.5oC), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs?

In 30 minutes

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.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area.

A group of expectant parents are touring the labor and birthing unit of a local hospital as part of their prenatal classes. When explaining the procedures used to prevent infant abduction, the nurse is less likely to point out which common factor about the abductor?

Targets a specific infant

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice

A nurse is conducting an refresher program for a group of nurses returning to work in the newborn clinic. The nurse nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional teaching is needed when the group identifies which parameter as being included in the assessment?

blood pressure

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?

"I will give him vitamin D supplements daily for the first 2 months of life."

The hospital is providing a class on newborn care to a group of parents prior to their discharge with their newborns. Which statement by a parent would indicate that further teaching is needed?

"If our baby turns red in the face and strains to have a stool that means she is constipated."

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?

0.5

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn?

Administer the medication into the anterolateral muscle.

The nurse is escorting the newborn to the transition nursery for the initial assessment and care. The nurse is prepared to carefully monitor the infant during the transition period, which occurs at which time interval?

First 6 to 12 hours

Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents?

General questions about different aspects of newborn care

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply.

Gonorrhea Chlamydia

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply.

Mongolian spots swollen genitals short, creased neck

A woman has just given birth vaginally to a newborn. Which action would the nurse do first?

Suction the mouth and nose.

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother?

This is a normal finding

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which signs might indicate a problem? Select all that apply.

labored breathing generalized cyanosis flaccid body posture

A nurse is assessing a newborn's gestational age. Which parameter would the nurse evaluate to assess physical maturity? Select all that apply.

lanugo genitals

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness

The nurse is teaching the parents of a newborn baby girl the basic discharge instructions. The nurse determines the session is successfull after the couple articulate they will contact the primary care provider if their infant shows which sign of diarrhea?

more than two episodes of diarrhea in one day

When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect?

pseudomenstruation, a normal finding

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?

Keep it dry.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

Blood sugar 42 mg/dL

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

blood sugar

The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame?

2 to 3 days after birth.

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full."

When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse interprets this finding as:

lanugo

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment?

rooting

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

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby?

"May I see your identification, please?"

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 Moro reflex. This reflex simulates the action of warding off an attacker."

In a class teaching new parents basic information on how to care for their new infant, the nurse should suggest that the parents plan to use how many diapers on a daily basis?

10

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%

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

24 hours after the newborn's first protein feeding

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

Apply petroleum gauze to the penis with each diaper change.

A nursing supervisor calls a nurse into his office to talk to the employee. The supervisor asks the nurse if she is wearing artificial nails and the nurse responds that she is. The supervisor tells her that she must remove them for what reason?

Artificial nails harbor bacteria and increase the spread of infection.

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?

Check the identification badge of any health care worker before releasing baby from room.

On inspecting a newborn's abdomen, which finding would you note as abnormal?

Clear drainage at the base of the umbilical cord

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?

Creases on two-thirds of the foot

The parents of a newborn are concerned that something is wrong with their newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn?

Follows a light to the midline

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 kangaroo care.

Which assessment finding indicates to the nurse that a newborn has hip subluxation?

Inability of the right hip to abduct

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the eyes from vaginal bacteria

The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?

Provides blood clotting factors

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

Redness at the base of the umbilical cord

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

Retracting the foreskin over the glans to assess for secretions

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What signs of distress would validate the nurse's concerns?

Temperature instability

Which nurse is practicing in a manner to reduce or eliminate pain in a newborn?

The nurse who suggests to the primary care provider to change ordered IM antibiotics to IV.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.

There is a family history of hemophilia. The infant is at 33 weeks' gestation.

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?

Wear clean gloves.

Assessment of a newborn reveals microcephaly. The nurse recognizes that this newborn may also have which complications? Select all that apply.

epilepsy cerebral palsy hearing disorders

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor?

A female in her mid-20s who appears pregnant

What supplies would the nursery nurse collect in preparation of doing a bath on a newborn infant? Select all that apply.

A washcloth Warm tub of water Thermometer

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears?

Both the mother and infant have identification bands that need to match.

A nursing instructor is conducting a class on the topic of circumcision. The instructor determines the class needs more education when they choose which factor as an advantage for having a circumcision?

Decreases risks of skin dehiscence, adhesions, and urethral fistulas

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein's pearls

The nurse is giving a newborn his first bath. What should the nurse prioritize?

Wash off all traces of blood and leave the vernix in place.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels

A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition?

erythema toxicum

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

All of the following are ways the nurse can encourage bonding between the parents and the newborn except:

telling the mother that the best way to bond with her baby is to breastfeed.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?

tetracycline ophthalmic ointment

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

within one hour

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?

Assess the newborn for signs of respiratory distress.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply.

Initiate early and frequent breast-feeding. Dry the newborn off immediately after birth to prevent chilling. Begin kangaroo care for the newborn.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress?

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis

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

Instruct the mom to feed every two to three hours.

The nurse in the newborn nursery is placing a 30-minute-old newborn on a radiant warmer for thermoregulation. Where should she apply the temperature probe to be most accurate?

Over the liver on the abdomen

The nurse is assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would the nurse apply to the surgical area?

Petrolatum gauze dressing

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best?

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching?

"Use talc powders to prevent diaper rash."

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

A nurse is teaching a newborn's parents how to change a diaper correctly. Which statement by the parents best demonstrates understanding of what they have been taught?

"We will fold down the front of her diaper under the cord until it falls off."

The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period?

12 hours

The parents of a newborn are concerned that the different procedures are causing pain for their newborn. Which action should the nurse prioritize to address the parent's concerns?

Advocate and use effective treatment methods that cause no pain or less pain.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed?

After the newborn has completed the antibiotic therapy

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

Cooperation by the parents with the hospital policies

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

Determine the mother's room temperature during the visit. Place a cap on the newborn and wrap her up in a blanket. Place the newborn's crib in the middle of the room away from the door.

The nursery head nurse is conducting an in-service on prevention of hypoglycemia to her staff. What information would she share with this group? Select all that apply.

Encourage breast-feeding 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.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein's pearls.

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.

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy?

The bedside glucometer is not calibrated for newborns.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?

The newborn will experience no bleeding episodes lasting more than 5 minutes.

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.

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

Using a bulb syringe, suction the mouth then the nose.

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.

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

A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply.

length of 54 cm weight of 3,300 grams temperature of 98.6° F (37° C)

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding?

nevus flammeus

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

the fat pads on the lateral aspects of the foot

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute

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?

Cover the glans generously with petroleum jelly.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply.

Jitteriness Lethargy Seizures

To maintain a sufficient fluid intake in a 3-month-old infant, the nurse should make which suggestions to the infant's mother?

Keeping track of the number of wet diapers/day is a good way of knowing the infant is getting enough fluid. The infant will need about 150-200 mL/kg of fluid intake/day. If the breast fed infant is having sufficient wet diapers, she is getting enough fluid.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions

The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? Select all that apply.

Place the infant on the back to sleep. Continue to breast-feed the baby until age 6 months. Do not provide the baby with a bottle while falling asleep.

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply.

Place the newborn in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure

A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.

A newborn weighed 7 lb, 3 oz (3220 g) at birth. Based on this birth weight, which procedure would be necessary for you to carry out?

Plotting his weight on a gestational age graph

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

Which newborn neuromuscular system adaptation would the nurse not expect to find?

an extrusion reflex at 9 months of age

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:

at least 24 hours after birth.

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 participates correctly choose which items will be on matching identification bracelets?

newborn's sex and date and time of birth

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?

the first 6 months

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

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

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery