Chapter 23 - Nursing Care of the Newborn and Family (Maternity) EAQ's

The nurse is assessing the body temperature of a neonate born 8 hours ago by placing the neonate on the mother's abdomen. The nurse finds that the neonate's body temperature is decreasing gradually. Based on these findings, the nurse concludes the mother's record to be normal. Which maternal condition is responsible for the neonate's decreasing body temperature? 1 The mother has undergone cesarean birth. 2 The mother has gestational hyperglycemia. 3 The mother has received Ringer's lactate solution. 4 The mother has been administered magnesium sulfate.

4 - The mother has been administered magnesium sulfate. pg 560 - The nurse places the neonate on the mother's abdomen to maintain thermoregulation. If the mother has been administered magnesium sulfate, the newborn may develop vasoconstriction. This reduces the newborn's ability to conserve heat. Although the birth was through cesarean section, the newborn's temperature should stabilize within 9 hours after the birth in extrauterine life. Neither gestational hyperglycemia nor Ringer's lactate solution would prevent thermoregulation between the neonate and the mother.

When weighing a newborn, what should the nurse do? 1 Leave its diaper on for comfort 2 Keep hand on the newborn's abdomen for safety 3 Place a sterile scale paper on the scale for infection control 4 Weigh the newborn at the same time each day for accuracy

4 - Weigh the newborn at the same time each day for accuracy pg 557 - The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above (not on) the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.

The nurse is assessing the neurologic activity of a neonate. What observation should the nurse report? 1 The ability to suck 2 Head circumference 3 Abdominal movements 4 Head-to-toe measurements

1 - The ability to suck pg 555 - The neurologic assessment of neonates is performed by determining reflex behaviors, such as sucking, rooting, and grasping. The head circumference and the body measurements indicate the physical growth of a neonate. The neonate's abdominal movements are related to the respiratory rate and do not relate to the neonate's neurologic activity.

With regard to umbilical cord care, what should nurses be aware of? 1 The stump can easily become infected. 2 The cord clamp is removed at cord separation. 3 The average cord separation time is 5 to 7 days. 4 A nurse noting bleeding from the vessels of the cord should immediately call for assistance.

1 - The stump can easily become infected. pg 599 - The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

While reading the medical record of a newborn, the nurse learns that the baby is suspected to have Potter syndrome. What observation from the newborn's assessment sheet validates this suspected condition? 1 Urinary output 2 Barrel-shaped chest 3 Webbing around the neck 4 Pinkish coloration of the skin

1 - Urinary output pg 568 - The nurse should check the newborn's urinary output to validate Potter syndrome, because a newborn with this condition does not void in the first 24 hours after birth. Therefore Potter syndrome will reduce the urinary output of the neonate. A barrel-shaped chest is a common finding in any newborn. Webbing around the neck region of the neonate is a primary symptom of Turner syndrome, but it is not associated with Potter syndrome. Pinkish coloration of the skin is a normal finding of any healthy neonate and is not associated with Potter syndrome.

A mother reports that her infant has a severe diaper rash. Upon assessment, the nurse finds that the mother wraps the diaper immediately after bathing the infant, without allowing the skin to properly dry. What medication does the nurse expect the primary health care provider to prescribe to prevent further excoriation? 1 Zinc oxide (Desitin) 2 Oral sucrose (Splenda) 3 Tetracycline (Sumycin) 4 Acetaminophen (Aceta)

1 - Zinc oxide (Desitin) pg 595 - The mother wraps the diaper immediately after bathing without allowing proper drying of the skin. The moisture on the skin results in diaper rash. Zinc oxide ointment (Desitin) can be used to protect the infant's skin from moisture and further excoriation. Oral liquid acetaminophen (Aceta) is a nonopioid analgesic used to treat mild and moderate inflammation. Oral sucrose (Splenda) is used to reduce the pain associated with surgeries. Tetracycline (Sumycin) is administered into the eyes of the infant to prevent ophthalmia neonatorum; it is not used to treat diaper rash.

The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse? 1 Wrap the neonate in a warm blanket 2 Administer vitamin K intramuscularly 3 Provide ventilator support to the neonate 4 Clean the neonate skin with lukewarm water

2 - Administer vitamin K intramuscularly pg 563/573 - Petechiae rashes observed on a neonate indicate that the neonate has a defect related to clotting factors. Based on this finding the nurse would expect the primary health care provider to order the administration of vitamin K to improve clotting formation. Ventilator support is given when the fetal heart rate (FHR) is noted to be less than 100 beats/min. A neonate is kept in a warm blanket along with the mother to maintain thermoregulation. Cleaning the skin of a neonate does not wipe away petechiae rashes; instead, cleaning is done to remove the bloodstains after birth.

The nurse administers concentrated oral sucrose through the suckling method to a neonate before performing the heelstick method. Why would the nurse do this? 1 To ensure hydration in the infant 2 As a source of comfort to the infant 3 To recognize the reflexes in the infant 4 To increase the glucose level in the infant

2 - As a source of comfort to the infant pg 591 - The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse administers oral sucrose to a neonate before performing a painful procedure such as the heelstick method to comfort the neonate. It is not necessary to hydrate the neonate before performing the heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize reflexes in infant.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. What should the nurse tell the parents to do? 1 Apply topical anesthetics with each diaper change 2 Expect a yellowish exudate to cover the glans after the first 24 hours 3 Apply constant pressure to the site if bleeding occurs and call the physician 4 Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes

2 - Expect a yellowish exudate to cover the glans after the first 24 hours pg 588 - Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.

The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored? 1 Syndactyly 2 Kernicterus 3 Rectal fistula 4 Down syndrome

2 - Kernicterus pg 575 - Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not associated with increased bilirubin levels.

The nurse is caring for a two-day-old term infant who was circumcised six hours ago. He is restless and fussy and refuses to breastfeed. The nurse attempts nonpharmacologic interventions with minimal results. What medication does the nurse expect the primary health care provider to order as an analgesic for the newborn? 1 Oral sucrose 2 Liquid acetaminophen 3 Intravenous (IV) fentanyl 4 Topical prilocaine-lidocaine (EMLA)

2 - Liquid acetaminophen pg 588 - Oral liquid acetaminophen is a nonopioid analgesic that may be used to reduce pain following circumcision. It may be administered every 4 hours, not to exceed 75 mg/kg/day. Oral sucrose may be given before circumcision along with 4% lidocaine as a topical anesthetic; it is not used to alleviate postcircumcision pain. Prilocaine-lidocaine (EMLA) is a local anesthetic applied topically prior to circumcision. Bolus or continuous IV infusion of opioids, like fentanyl, provide effective pain control with low incidence of adverse effects; however, these are most often used for more severe pain.

Upon assessing the laboratory reports of an infant, the nurse finds an abnormality in the infant's bone development. The nurse instructs the parents to perform periodic checkups and monitor the growth of the infant. What did the nurse find in the infant's laboratory reports? 1 Low methionine levels 2 Low thyroxine (T4) levels 3 Decreased galactose levels 4 Decreased phenylalanine levels

2 - Low thyroxine (T4) levels pg 563 - Low T4 levels may retard the growth of the infant. Therefore it is important to monitor the regular growth of the infant, particularly pertaining to bone growth. Low levels of galactose may affect the immune system in the body, making it nonfunctional. Low methionine levels may cause liver damage. Low phenylalanine levels lead to intellectual disability in infants. However, low levels of galactose, methionine, and phenylalanine do not affect the bone growth of the child. Therefore it is not suggested to monitor the bone growth if any of these chemical molecules decreases in the infant.

The nurse is performing an evaluation and screening of a newborn. To estimate the blood glucose levels, the nurse collects blood from the infant by the heelstick method. What nursing intervention would be accurate while performing the heelstick method? 1 Make a puncture no deeper than 3 mm into the neonate's heel 2 Make a puncture no deeper than 2.4 mm into the neonate's heel 3 Make a puncture no deeper than 2 mm on the right side of the neonate's heel 4 Make a puncture no deeper than 1 mm on the right side of the neonate's heel

2 - Make a puncture no deeper than 2.4 mm into the neonate's heel pg 582 - To avoid necrotizing osteochondritis in the newborn, the puncture is made no deeper than 2.4 mm in the heel. Therefore making a puncture 2 mm deep in the heel is the correct intervention. If the puncture is made 3 mm deep into the heel, it would result in lancet penetration of the bone. Therefore the nurse would not make a puncture 3 mm deep. The heelstick method is performed in the heel, not on the sides of the heel. Therefore making a puncture that is 2 mm or 1 mm deep on the right side of the heel is an incorrect action.

The nurse is caring for an infant with candidiasis. Despite being treated with topical clotrimazole (Pedesil), the infection persists. Which medication does the primary health care provider prescribe? 1 Oral fentanyl (Sublimaze) 2 Oral nystatin (Mycostatin) 3 Topical miconazole (Desenex) 4 Morphine infusion (Duramorph)

2 - Oral nystatin (Mycostatin) pg 595 - Persistence of the candidiasis even after antifungal therapy indicates any gastrointestinal source of infection. To eliminate any gastrointestinal source of candidiasis, oral nystatin (Mycostatin) is prescribed. Oral fentanyl (Sublimaze) is an analgesic and does not combat the infection in the body. Topical miconazole (Desenex) is of no use in this condition, because the infection is internal and it is used to treat fungal infections on the skin. Intravenous (IV) morphine infusion (Duramorph) is an analgesic. It is not used to treat candidiasis.

The nurse is assessing a preterm baby and observes dark red skin color with harlequin signs on the skin. What does the nurse infer that the baby has from these findings? 1 Hypotension 2 Polycythemia 3 Hyperthermia 4 A neurologic disorder

2 - Polycythemia pg 563 - The dark red color skin of the newborn with harlequin signs indicates polycythemia. Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs). The presence of hypotension in the infant is indicated by gray coloration of the skin. The presence of hyperthermia in a newborn is indicated by blue coloration (cyanosis) of the skin. Neurologic disorders are associated with cyanosis but not with polycythemia.

The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate's BP confirm a cardiac defect? 1 The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg. 2 The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. 3 The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg. 4 The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.

2 - The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. pg 557 - Systolic BP should be 60 to 80 mm Hg, and diastolic BP should be 40 to 50 mmHg. When the recordings are varied by 20 mm Hg in both the extremities, it implies that the neonate has a cardiac defect, such as coarctation of the aorta. If the BP of the lower extremities is 50/40 mm Hg and that of the upper extremities is 80/70 mm Hg, it indicates that the neonate has a cardiac defect, such as coarctation of the aorta. The same recordings on all the extremities signify that the neonate's heart functions properly. Variations of 10 mm Hg are still considered a normal finding in a neonate.

The nurse is assessing a neonate who has undergone phototherapy. The nurse finds the transcutaneous bilirubinometry (TcB) reading to be 13 mg/dL. What should the nurse infer about the neonate from these findings? 1 The neonate has not been breastfed. 2 The neonate may require blood transfusion. 3 The neonate requires intravenous dextrose infusion. 4 The neonate needs to receive oral acetaminophen (Tylenol).

2 - The neonate may require blood transfusion. pg 577 - A transcutaneous bilirubinometry (TcB) reading greater than 12 mg/dL indicates excessive serum unconjugated bilirubin levels. If these levels persist even after the phototherapy, the neonate may require blood transfusion to decrease the serum unconjugated bilirubin levels. Breastfeeding the neonate increases the gastric motility and eliminates excess bilirubin. Therefore breastfeeding is encouraged during hyperbilirubinemia. Oral acetaminophen (Tylenol) is given to alleviate the pain in a neonate associated with procedures such as circumcision. Dextrose infusion is administered when a neonate has low glucose levels.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. What should be parents taught to do? 1 Avoid use of pacifiers 2 Use a rear-facing car seat 3 Use a crib with side rail slats that are no more than 3 inches apart 4 Place the newborn on the abdomen (prone) after feeding and for sleep

2 - Use a rear-facing car seat pg 594 - The newborn should be in a rear-facing infant car safety seat from birth until 2 years of age or until exceeding the car seat's limits for height and weight. The prone position is no longer recommended because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Slats in a crib should be no more than 2 inches apart.

The student nurse asks the clinical instructor about changes in normal elimination patterns of infants. Which response given by the clinical instructor is most appropriate? 1 "Formula-fed infants pass more stools every day than breastfed infants." 2 "Formula-fed infants' stools are less offensive than breastfed infants' stools." 3 "Breastfed infants should pass stools three times a day for the first few weeks." 4 "The stools of formula-fed infants should resemble mustard mixed with cottage cheese."

3 - "Breastfed infants should pass stools three times a day for the first few weeks." pg 595 - Breastfed infants should pass stools three times a day for the first few weeks. Any deviation from this indicates problems related to stooling. Formula-fed infants have fewer stools than breastfed infants. The formula-fed infants may have as few as one stool every other day after the first few weeks. The odor of the stools of formula-fed infants is more offensive than that of infants who are breastfed. The stools of breastfed infants are looser and resemble mustard mixed with cottage cheese.

The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe? 1 "It is used in the baby to prevent defecation from the anal opening." 2 "It is used in the baby to reduce the temperature during hypothermia." 3 "It is used in the baby to prevent suffocation and clear airway obstruction." 4 "It is used in the baby to avoid heat loss due to evaporation and convection."

3 - "It is used in the baby to prevent suffocation and clear airway obstruction." pg 571 - The bulb syringe is used to prevent suffocation and clear airway obstruction of newborns, and hence, it prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the newborn carefully, and avoiding exposing the newborn to drafts.

The nurse is teaching a student nurse about stool patterns of a breastfed infant. What statement made by the student nurse indicates the need for further teaching? 1 "Watery stools are considered normal." 2 "Green-colored stools are considered diarrhea." 3 "Stool would have a water ring in normal conditions." 4 "Stool frequency may be three times a day in normal condition."

3 - "Stool would have a water ring in normal conditions." pg 602 - Stools in a normal breastfed neonate will not have a water ring. Presence of a water ring in a stool indicates that the infant has diarrhea. Watery stools are normal findings of breastfed neonates. Green-colored stool indicates diarrhea. A breastfed neonate has a stool frequency of more than three times per day.

The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects? 1 Measure the circumference of the head 2 Assess movements of the lower extremities 3 Assess blood pressure (BP) in all four extremities 4 Monitor blood pressure (BP) in the upper extremities

3 - Assess blood pressure (BP) in all four extremities pg 557 - When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out congenital heart diseases. Circumference of the head is measured to detect head-related complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart disease. Assessing the body movements would correlate more with the muscular activity of the neonate but not with cardiac activity.

The nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools? 1 Administration of glucose water 2 Administration of infant formula 3 Bilirubin-induced gastric motility 4 Decreased body fluids in the body

3 - Bilirubin-induced gastric motility pg 579 - The breakdown of bilirubin increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. The infant's buttocks must be cleaned after each stool to maintain skin integrity. Loose stools are not caused by decreased body fluids; instead, the loose stools lead to decreased body fluids and dehydration in the body. Administration of glucose water or plain water perpetuates enterohepatic circulation but delays the bilirubin excretion from the body. Administration of infant formula after phototherapy is highly beneficial to the infant to combat dehydration resulting from fluid loss from the body. However, it does not lead to loose stools.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? 1 Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours 2 Wash off the yellow exudate that forms on the glans at least once every day to prevent infection 3 Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change 4 Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs

3 - Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change pg 587 - With each diaper change, the penis should be washed off with warm water, not prepackaged diaper wipes, to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day 2 Cut the nails while the baby is playing 3 Cut the nails while the baby is sleeping 4 Cut the nails while breastfeeding the baby 5 Cover the baby's hands with loose-fitting mitts

3 - Cut the nails while the baby is sleeping 5 - Cover the baby's hands with loose-fitting mitts pg 601 - The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.

The nurse is assessing a newborn undergoing phototherapy. What changes would the nurse likely notice in the newborn during the process? 1 Increased urinary output 2 Increased blood pressure 3 Increased stool frequency 4 Increased skin discoloration

3 - Increased stool frequency pg 577 - Phototherapy is performed in the newborn with increased bilirubin levels (jaundice). During this process excess bilirubin is eliminated through stools and increases the gastric motility. Therefore the nurse may observe an increase in stool frequency in a newborn. Urinary output may be reduced or may remain unaltered as a result of hydration, but it does not increase during the phototherapy session. An increase in blood pressure in the newborn is a rare observation and is not associated with phototherapy. During phototherapy the yellow discoloration of the skin caused by jaundice is reduced, not increased.

The nurse is assessing a preterm infant with no muscle mass. The primary health care provider instructs the nurse to administer vitamin K to the infant. What route of administration does the nurse choose for diluted vitamin K? 1 Oral route over 10 to 15 minutes 2 Ophthalmic route over 10 to 15 minutes 3 Intravenous (IV) route over 10 to 15 minutes 4 Intramuscular (IM) route over 10 to 15 minutes

3 - Intravenous (IV) route over 10 to 15 minutes pg 573 - Vitamin K is typically administered through the IM route for infants. Because the infant is preterm with no muscle mass, vitamin K is administered in a diluted form through the IV route over 10 to 15 minutes. Because infants have underdeveloped digestive systems, vitamin K is not administered orally. The ophthalmic route is not advised, because vitamin K is not administered to treat eye disorders. Vitamin K is not administered via the IM route in the case of a preterm infant with no muscle mass.

Which statement provides helpful and accurate nursing advice concerning bathing the newborn? Select all that apply. 1 Bathe immediately after feeding while baby is calm and relaxed. 2 Only plain warm water can be used to preserve the skin's acid mantle. 3 Powders are not recommended because the infant can inhale powder. 4 Newborns should be bathed every day, for the bonding as well as the cleaning. 5 Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed.

3 - Powders are not recommended because the infant can inhale powder. 5 - Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. pg 598/599 - Tub baths may be given as soon as an infant's temperature has stabilized. Powder is not recommended because of the risk of inhalation. If a parent chooses to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Unscented mild soap is appropriate to use to wash the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.

The nurse is caring for a 3-week-old infant. Upon assessment the nurse finds that the infant has impaired acoustic nerve functioning. What does the nurse infer from this finding about the infant's clinical condition? 1 The infant has cataracts in the eye. 2 The infant has regular laryngospasms. 3 The infant has reduced hearing abilities. 4 The infant has persisting petechiae on the skin.

3 - The infant has reduced hearing abilities. pg 582 - The hearing function of an infant is assessed by examining acoustic nerve stimulations. This can be performed with the evoked otoacoustic emissions (EOAE) test and auditory brainstem response (ABR) test. Cataracts are usually observed in an infant with elevated galactose levels. Impaired acoustic nerve stimulation does not indicate laryngospasms. Laryngospasms in an infant signifies lowered calcium levels. Persisting petechiae indicate an underlying hemorrhage disorder in an infant and are not related to the acoustic nerve stimulations.

Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this? 1 The infant wakes up frequently. 2 The infant's skin has a pink complexion. 3 The infant requires 40% oxygen support. 4 The infant's heart rate was 110 beats/min.

3 - The infant requires 40% oxygen support. pg 590 - According to the CRIES scale, the infant is experiencing severe pain when he or she requires more than 30% oxygen support to maintain normal functioning. The normal heart rate of an infant is 110 beats/min. The heart rate increases when the infant cries. The infant waking frequently does not necessarily indicate severe pain. A pink complexion is a normal indication, so a pink complexion does not cause the nurse to conclude that the infant is in severe pain.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? 1 The neonate has hypothermia. 2 The neonate had stress during birth. 3 The neonate exhibits normal findings. 4 The neonate has an infected umbilicus

3 - The neonate exhibits normal findings. pg 555 - An Apgar score of 7 to 10 indicates that the baby is normal with less difficulty adjusting to extrauterine life. Observations such as a pink complexion and a heart rate of more than 100 beats/min indicate that the baby is normal. Therefore the nurse would rate the child a score of 7 to 10. An Apgar score of 4 to 6 indicates hypothermia, because the infant shows moderate difficulty in adapting to extrauterine life. Scores of 0 to 3 indicate severe stress during birth and may show alterations in heart rate and respiration. Infection of the umbilicus may occur because of difficulty in adapting to extrauterine life and is not a normal finding in a child.

During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? 1 The neonate has hypothermia. 2 The neonate had stress during birth. 3 The neonate exhibits normal findings. 4 The neonate has an infected umbilicus.

3 - The neonate exhibits normal findings. pg 555 - An Apgar score of 7 to 10 indicates that the baby is normal with less difficulty adjusting to extrauterine life. Observations such as a pink complexion and a heart rate of more than 100 beats/min indicate that the baby is normal. Therefore the nurse would rate the child a score of 7 to 10. An Apgar score of 4 to 6 indicates hypothermia, because the infant shows moderate difficulty in adapting to extrauterine life. Scores of 0 to 3 indicate severe stress during birth and may show alterations in heart rate and respiration. Infection of the umbilicus may occur because of difficulty in adapting to extrauterine life and is not a normal finding in a child.

The primary health care provider instructs the nurse to administer hepatitis B immune globulin (HBIG) to a neonate within 12 hours of birth. The neonate was born to a mother whose HBsAg status is unknown. What does the nurse infer from such instruction? 1 Polycythemia is present. 2 The mother weighed 65 kg at birth. 3 The neonate weighs 2000 g or less. 4 Maternal gestational hypertension is present.

3 - The neonate weighs 2000 g or less. pg 586 - HBIG must be administered within 12 hours of birth to an infant born to a mother whose HBsAg status is unknown if the infant weighs less than or equal to 2000 g. Administration of HBIG is not prescribed for polycythemia. The mother's weight is not a factor to be considered for administration of HBIG to the newborn, because it has no effect on the vaccination. Similarly, gestational hypertension of the mother does not affect the administration of HBIG to the newborn.

The primary health care provider instructs the nurse to give a hepatitis B (HepB) vaccine to a newborn. How should the nurse administer the vaccine? Select all that apply. 1 Through the deltoid muscle 2 Via the dorsogluteal muscle 3 Using the vastus lateralis muscle 4 By inserting the needle at a 60-degree angle 5 By inserting the needle at a 90-degree angle

3 - Using the vastus lateralis muscle 5 - By inserting the needle at a 90-degree angle pg 585 - The preferred injection site for a newborn is the vastus lateralis muscle in the thigh at a 90-degree angle. This is the best choice because this muscle has an adequate amount of muscle mass and fat. Administration of the hepatitis B (HepB) vaccine through the deltoid muscle is not recommended in infants, because this muscle has an inadequate amount of muscle for intramuscular (IM) administration. The dorsogluteal muscle is very small, poorly developed, and dangerously close to the sciatic nerve, which occupies a proportionately larger area in infants than in older children. Therefore it is not recommended as an injection site in newborns. The administration of the HepB vaccine is done by inserting the needle at a 90-degree angle, not at a 60-degree angle.

The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this? 1 "Are you applying A&D ointment while cleaning?" 2 "Are you cleaning the penis with lukewarm water?" 3 "Are you applying fresh petrolatum while cleaning?" 4 "Are you cleaning with prepackaged commercial wipes?"

4 - "Are you cleaning with prepackaged commercial wipes?" pg 588 - Do not use prepackaged commercial baby wipes for cleaning the circumcised site because they can contain alcohol. Alcohol delays healing and also causes discomfort to the infant. The infant cries out loudly because of the discomfort. Washing the penis gently with lukewarm water is recommended to remove urine and feces. Fresh petrolatum is applied to reduce pain after each diaper change. The application of A&D ointment while cleaning is done to prevent the sticking of the penis to the discharge, as well as to increase the infant's comfort.

The nurse is educating a group of new mothers about the use of pacifiers for their infants. Which statement does the nurse include in the teaching? 1 "Pacifiers should be designed and prepared at home." 2 "Pacifiers should be reinserted once the infant falls asleep." 3 "Pacifiers should be coated with any type of sweet solution." 4 "Pacifiers should be constructed as one piece with a shield."

4 - "Pacifiers should be constructed as one piece with a shield." pg 598 - Pacifiers that are made of one piece and include a shield or flange large enough to prevent entry into the mouth with a handle can be used safely. Homemade pacifiers may not be perfectly designed and may pose danger to the infant because the entire object or a portion may lodge into the pharynx. The pacifiers should not be reinserted into the mouth of the infant once the infant falls asleep, because it may disturb the infant's sleep. Pacifiers should not be coated with any type of sweet solution.

The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition? 1 A body weight of 7 pounds 2 A heart rate 120 beats/min 3 A head-to-heel length of 55 cm 4 A head circumference greater than chest circumference

4 - A head circumference greater than chest circumference pg 562 - Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4.5 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/min indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.

The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them? 1 Evaluate the size of the nipples 2 Measure the circumference of the head 3 Observe the symmetry of lip movement 4 Apply pressure on the forehead with a finger

4 - Apply pressure on the forehead with a finger pg 577 - Distinction of cutaneous jaundice from normal skin color can be done by applying pressure on the forehead, nose, and sternum. The pressure on all these parts of the body can be applied with the finger for several seconds to empty all the capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Nipple size can be evaluated to ensure the prominence of nipples. Symmetry of lip movement should be observed to detect seventh cranial nerve paralysis. Measuring the circumference of the head is done to determine the microcephaly or hydrocephaly.

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. What should the nurse do? 1 Apply directly over the cornea 2 Flush eyes 10 minutes after instillation to reduce irritation 3 Instill within 15 minutes of birth for maximum effectiveness 4 Cleanse eyes from inner to outer canthus before administration

4 - Cleanse eyes from inner to outer canthus before administration pg 572 - The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.

The nurse observes a tissue injury in a newborn caused during birth. The nurse blanches the skin and finds no change in the affected area. What type of injury does the baby have? 1 Skin rash on the face 2 Edema in the buttocks 3 Discoloration in the neck 4 Ecchymosis on the trunk

4 - Ecchymosis on the trunk pg 576 - When the nurse notices an injury in the newborn, the nurse blanches the skin to verify the type of changes that are exhibited. If the newborn has ecchymosis or petechiae, no changes will be observed from the blanching. This is because extravasated blood remains within the tissues when infants have ecchymosis. A skin rash or discoloration of the neck may change color when blanched. Edema is swelling caused by the force applied during the birth process. The nurse would not need to blanch the edematous skin, because it is easily observed and noticed.

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min

4 - Heart rate of 70 beats/min pg 555 - The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.

The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant? 1 Intravenous (IV) hepatitis B vaccine 2 Intramuscular (IM) hepatitis B vaccine 3 Intravenous (IV) hepatitis B immune globulin (HBIG) 4 Intramuscular (IM) hepatitis B immune globulin (HBIG)

4 - Intramuscular (IM) hepatitis B immune globulin (HBIG) pg 585 - A dose of IM HBIG should be given to the infant whose mother's hepatitis B surface antigen's (HBsAg) status is determined to be positive. The vaccine is also given to infants who weigh 2000 g or more before 1 week of age. The hepatitis B vaccine and HBIG are not given through the IV route in infants because of their adverse effects. The IM hepatitis B vaccine is given to infants born to hepatitis B surface antigen (HBsAg)-negative mothers before being discharged from the hospital.

The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise? 1 Cow's milk orally 2 Infant formula orally 3 Intravenous (IV) saline infusion 4 Intravenous (IV) dextrose infusion

4 - Intravenous (IV) dextrose infusion pg 580 - If the glucose levels are less than 25 mg/dL in the first 4 hours, or less than 35 mg/dL in the first 4 to 24 hours, it indicates hypoglycemia. All infants at risk for hypoglycemia should be fed within the first hour, with glucose testing performed 30 minutes after breastfeeding. If the glucose levels remain low despite feeding, IV dextrose is prescribed to the newborn. Cow's milk is generally not preferred for infants, because it may cause infections. Administration of infant formula is recommended in infants with hypocalcemia. IV saline infusion is not beneficial to hypoglycemic infants, because a saline infusion consists of plain salts and does not increase the glucose levels in the body.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on what? 1 Petechiae usually occur with forceps delivery. 2 Petechiae result from increased blood volume. 3 Petechiae should always be further investigated. 4 Petechiae are benign if they disappear within 48 hours of birth.

4 - Petechiae are benign if they disappear within 48 hours of birth. pg 576 - Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, what should the nurse do? 1 Cover the probe with a nonreflective material 2 Place the thermistor probe on the left side of the chest 3 Recheck the temperature by periodically taking a rectal temperature 4 Prewarm the radiant heat warmer and place the undressed newborn under it

4 - Prewarm the radiant heat warmer and place the undressed newborn under it pg 579 - The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.

The nurse is assessing a neonate who is administered vitamin K intramuscularly (IM). What changes in the neonate would the nurse primarily monitor to ensure safety? 1 Increased heart rate 2 Increased body moments 3 Pink coloration of the skin 4 Yellow discoloration of sclera

4 - Yellow discoloration of sclera pg 573 - After vitamin K is administered, neonates develop jaundice-like side effects. Therefore the nurse should look for a yellow discoloration in neonates who have been administered vitamin K. Increased heart rate is a very rare complication observed in neonates. It is primarily observed when a neonate cries, but not when vitamin K is administered IM. Increased body movements may indicate Down syndrome and are not adverse effects of vitamin K. Pink coloration of the skin is a normal finding in neonates and is not associated with jaundice-like effects.

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________. Record your answer as a whole number.

Answer - 9 pg 555 - The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis.

The nurse is taking care of a newborn who is not yet circumcised. Which anesthetic agent does the nurse expect the primary health care provider to prescribe? 1 4% lidocaine (LMX4) 2 Morphine (Morphine) 3 Atracurium (Tracrium) 4 Hyoscyamine (Symax)

1 - 4% lidocaine (LMX4) pg 587 - Eutectic mixture of 4% lidocaine (LMX4) is given as a topical anesthetic to the circumcised newborn. Hyoscyamine is used to provide symptomatic relief in various gastrointestinal disorders, such as spasms, peptic ulcers, irritable bowel syndrome, diverticulitis, pancreatitis, colic, and cystitis. Morphine is primarily used to treat both acute and chronic severe pain in a circumcised patient. It is also used to manage pain caused by myocardial infarction and labor. Atracurium (Tracrium) is a muscle relaxant used during circumcision, not before the surgery.

The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant? 1 9 hours after the infant is born 2 13 hours after the infant is born 3 14 hours after the infant is born 4 18 hours after the infant is born

1 - 9 hours after the infant is born pg 585 - If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within 12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth, not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than 2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.

The nurse is assessing a newborn with laryngospasms who is crying in a high-pitched voice. The mother's medication history shows the use of anticonvulsants during pregnancy. What is the nurse likely to infer about the newborn's condition? 1 A reduction in calcium levels 2 A reduction in glucose levels 3 A reduction in bilirubin levels 4 A reduction in clotting factors

1 - A reduction in calcium levels pg 580 - Crying in a high-pitched voice and laryngospasms are symptoms of hypocalcemia (reduced calcium levels) in newborns. If the mother was receiving anticonvulsant therapy during pregnancy, there is a greater risk for the child to have lower calcium levels. Irritability and jitteriness are symptoms of reduced glucose levels. The mother's history of diabetes or prolonged labor would increase the risk for hypoglycemia in the newborn. Reduced clotting factors are suspected when the newborn's skin has persisting petechiae for more than 2 days after birth. Reduced bilirubin levels are not found in the newborn. However, an increased level of bilirubin is a common finding.

On a winter morning the nurse finds the skin color of the newborn turning blue. The baby also has difficulty breathing. What should be the immediate nursing interventions to restore a normal condition in the baby? Select all that apply. 1 Administer glucose to the newborn 2 Administer normal saline to the newborn 3 Provide artificial ventilation to the newborn 4 Set the incubator at a temperature above 22° C 5 Administer vitamin K intramuscularly in the newborn

1 - Administer glucose to the newborn 3 - Provide artificial ventilation to the newborn 4 - Set the incubator at a temperature above 22° C pg 572 - The bluish skin color of the newborn is due to difficulty breathing, caused by cold stress. The cold stress increases the respiratory rate in the newborn, thereby depleting the glucose levels. Lack of oxygen causes the bluish tone of the skin. The nurse should administer glucose immediately to the newborn to restore the levels of glucose. Additionally, artificial ventilation is provided to restore the oxygen levels within the baby. The baby should be transferred to an incubator, which is maintained at a temperature of 22° to 26° C, because this helps combat the cold stress. Administration of normal saline cannot restore the glucose levels or promote oxygenation. Vitamin K is generally administered to all newborns to prevent bleeding, but it will not restore the glucose in the newborn or help with thermoregulation.

A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? 1 Administer ophthalmic solution 2 Place the newborn in incubator 3 Perform a heelstick puncture test 4 Provide ventilator support to the newborn

1 - Administer ophthalmic solution pg 572 - The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred in order to regulate the body temperature when a neonate has hypothermia. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/min. However, the heart rate is not decreased due to gonorrheal infection.

The primary health care provider (PHP) prescribes ventilator support for a newborn. What finding would the PHP have assessed in the newborn? 1 Bluish discoloration of the skin 2 Yellowish discoloration of the skin 3 Edema in the legs of the newborn 4 Cataracts in the eye of the newborn

1 - Bluish discoloration of the skin pg 572 - Bluish discoloration of the skin is a symptom of cyanosis. It is associated with breathing difficulties, which reduce the oxygen levels in the body. This oxygen deprivation turns the skin blue. The immediate medical intervention includes ventilator support to restore the oxygen levels in the body. Yellow discoloration of the skin signifies increased bilirubin levels, which requires phototherapy; however, it may not require ventilator support. Edematous legs are usually observed in a newborn when the birth process is prolonged. The condition generally resolves in a couple of days after birth. Cataracts are observed in an infant with elevated galactose levels and does not require ventilator support.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by which procedures? Select all that apply. 1 Keep a bulb suction available at home. 2 Do not let the infant sleep on his or her back. 3 Keep the infant away from secondhand smoke. 4 Avoid loose bedding, waterbeds, and beanbag chairs. 5 Prevent exposure to people with upper respiratory tract infections.

1 - Keep a bulb suction available at home. 3 - Keep the infant away from secondhand smoke. 4 - Avoid loose bedding, waterbeds, and beanbag chairs. 5 - Prevent exposure to people with upper respiratory tract infections. pg 594 - Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the mouth and nose at home to protect the airway.

A patient vaginally delivers an infant at 36 3/7 weeks gestation. Following delivery, the infant receives a 9/9 Apgar score, and the vital signs obtained are T 97.9, R 62, and HR 156. Based on this assessment, what is the nurse's priority action? 1 Obtain a pulse oximetry value. 2 Suction the infant with a bulb syringe. 3 Place the infant skin to skin with the mother. 4 Continue to observe the newborn in the radiant warmer.

1 - Obtain a pulse oximetry value. pg 582 - The nurse's priority action is to obtain a pulse oximetry value. The newborn is experiencing tachypnea (60 respirations/min or more), which is a sign of abnormal breathing. Furthermore, the birth occurring between 34 0/7 and 36 6/7 weeks of gestation is considered late preterm. The late preterm infant is at an increased risk for many problems, including respiratory distress. Bulb suctioning is used to remove excess mucus. The infant can be placed skin to skin with the mother when the infant is stabilized. Continuing to observe the newborn without further assessment or intervention may result in respiratory distress.

The nurse is caring for an infant who cries in a high-pitched voice. When the crying ceases, the nurse wants to check the blood pressure (BP) of the newborn. What device does the nurse most preferably use? 1 Oscillometric monitor 2 Aneroid sphygmomanometer 3 Mercury sphygmomanometer 4 Ultrasonic Doppler flow meter

1 - Oscillometric monitor pg 557 - An oscillometric monitor is a device used to check the BP in neonates. It is an easy-to-operate digital monitor and does not cause any pain to the infants while it is being used. Aneroid sphygmomanometers and mercury sphygmomanometers are the manual sphygmomanometers and are difficult to use for checking the BP of infants. An ultrasonic Doppler flow meter is the device used for evaluating the hemodynamics of the vascular system (blood flow).

The nurse is assessing a 3-day-old infant with ecchymosis and finds that the condition has not yet healed. The nurse informs the primary health care provider (PHP) of this finding. Which laboratory report would the nurse expect the PHP to order? 1 Platelet count 2 Bilirubin levels 3 Abdominal scan 4 Creatinine levels

1 - Platelet count pg 576 - Ecchymosis is observed in a newborn as a result of injury caused during delivery. This condition usually heals within 2 days of childbirth. If the condition persists for more than 2 days, the PHP will order to test the platelet count to rule out thrombocytopenic purpura. Thrombocytopenic purpura may be the underlying cause for persistent ecchymosis. Bilirubin levels are usually checked when there is a discoloration of the skin, but not for ecchymosis. Abdominal scan and serum creatinine levels are not helpful in determining thrombocytopenic purpura.

The nurse assesses the circumcision site of an infant every 20 minutes for the first hour to check for bleeding. The nurse identifies uncontrollable bleeding at the site. What is the most important nursing intervention? 1 Prepare for blood vessel ligation 2 Clean the bleeding site continuously 3 Administer an analgesic to reduce the pain 4 Apply strong pressure to stop the bleeding

1 - Prepare for blood vessel ligation pg 588 - If the bleeding from the circumcision site is not easily controlled, then the blood vessel may need to be ligated. In this event, the nurse will notify the primary health care provider. Cleaning the bleeding site continuously is recommended to avoid infection. However, it does not reduce bleeding from the circumcision site. Administering an analgesic reduces the pain at the site of the circumcision but does not reduce the loss of blood from the site. The nurse applies gentle pressure with a folded sterile gauze pad. The nurse should not apply strong pressure on the site, because it increases the pain.

The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate? 1 Provide warmth to the neonate 2 Provide ventilator support to the neonate 3 Provide chest compressions to the neonate 4 Clean the neonate's body with lukewarm water

1 - Provide warmth to the neonate pg 572 - The neonate born on the way to hospital may become hypothermic, so the nurse should gradually warm the neonate's body to avoid apneic spells (insufficiency breathing). Rapid warming may cause apneic spells. Thus the warming process should be gradual. Ventilator support or chest compressions are given when a neonate already has respiratory distress, which is identified by assessing the heart rate. The nurse can use lukewarm water to clear the stains on the neonate's body only after thermal stability is achieved.

The nurse is collecting a neonate's blood sample by the heelstick method. What safety measure will the nurse follow to prevent necrotizing osteochondritis in the neonate? 1 Puncture the skin up to 2.4 mm 2 Repeat the procedure on the other side 3 Apply cold pressure before the puncture 4 Make an imaginary line on the hip before making the puncture

1 - Puncture the skin up to 2.4 mm pg 582 - When performing the heelstick method, the nurse punctures the heel of a neonate at a depth of 2.4 mm to prevent necrotizing osteochondritis. The nurse should apply warm pressure, not cold pressure, before performing the puncture. The nurse would make an imaginary line before puncturing the heel of a newborn, but the line is not on the hip. The nurse would not repeat the test on the other side to prevent necrotizing osteochondritis, but rather will perform the test accurately the first time.