Lesson 7: Care of the Newborn
A nurse is preparing to apply erythromycin ophthalmic ointment to a newborn's eyes. Which action should the nurse plan to take? 1. Cleansing the infant's eyes before applying the ointment 2. Applying the ointment to the upper conjunctival sac of each eye 3. Rinsing the excess ointment from the eye using normal saline solution 4. Applying the ointment from the outer canthus to the inner canthus of the eye
(!) The infant's eyes are cleansed before the administration of eye ointment. The ointment is placed in the lower conjunctival sac of each eye and deposited from the inner canthus to the outer canthus. The ointment is not rinsed from the eye, although it may be wiped from the outer eye area after 1 minute.
A nurse performing an initial assessment of a newborn who is awake and alert counts the infant's apical heart rate and obtains a rate of 130 beats/min. Based on this finding, which action should the nurse take? 1. Documenting the finding 2. Contacting the pediatrician 3. Reassessing the heart rate in 5 minutes 4. Stimulating the infant and reassessing the heart rate
(1) The normal heart rate of a newborn infant is 100 to 160 beats/min. Therefore the nurse would document the finding. The other options are incorrect and unnecessary.
Calculate the APGAR score for the following newborn: - Appearance: normal with cyanotic extremities - Pulse: 130 - Grimace: when stimulated by suctioning - Activity: minimal flexion of extremities - Respiratory: weak cry
(6) The Apgar score is a method used to express the findings of a rapid assessment of the newborn as he or she enters extrauterine life. The five categories are HR, Respiratory Efforts (observed by RR and crying effort), muscle tone (based on movement), reflex irritability( based on the newborn's response to the bulb/ catheter suctions of the nasopharynx), and general skin color. Apgar evaluations are made at 1 and 5 minutes after birth
Maureen and Robert decide to have James Nicholas circumcised before he is discharged from the hospital. The nurse conducts teaching for home care of the circumcised newborn. Which statement by Maureen indicates a need for further instruction? 1. "I'll clean the penis with a baby wipe during each diaper change." 2. "I'll check the circumcision site for bleeding during each diaper change." 3. "I'll apply petroleum jelly to the penis during each diaper change until it heals." 4. "If his penis turns red, swells, or has a discharge, I'll call the pediatrician right away."
(1) Many newborn infants are discharged soon after circumcision, and thorough client teaching is important. Parents should be taught to check carefully for bleeding, to cleanse the site with warm water until the circumcision is healed (5 to 6 days), and to apply petroleum jelly during each diaper change until the site is healed. Redness, swelling, or discharge indicates infection, and the health care provider should be notified immediately if any of these findings is noted. Commercial baby wipes should not be used because they contain alcohol, which may delay healing and cause discomfort for the newborn.
A nurse assessing a newborn's reflexes tests the Babinski (plantar) reflex. The nurse notes that when the reflex is elicited, the infant's toes hyperextend and the big toe dorsiflexes. How should the nurse document this finding? 1. Positive 2. Negative 3. Unresponsive 4. Depressed
(1) To elicit the Babinski reflex, the nurse begins at the heel of the foot and strokes upward along the lateral aspect of the sole of the foot, then moves the finger across the ball of the foot. In the characteristic response, all toes hyperextend and the big toe dorsiflexes. This is recorded as a positive sign. Although the response depends on general muscle tone and condition of the infant, an absence of response requires neurological evaluation. Therefore the other options are incorrect.
A mother changing her newborn daughter's diaper notes the presence of a small amount of blood on the infant's labia. The mother is concerned and tells the nurse that the infant is bleeding from the vaginal area. After assessing the infant, what response does the nurse provide to the mother? 1. The pediatrician will need to check the infant. 2. A small amount of vaginal bleeding is normal. 3. The bleeding is nothing to be concerned about. 4. The bleeding is probably a result of trauma from the birth process.
(2) In the full-term female infant, edema of the labia and a white mucous vaginal discharge are normal. A small amount of vaginal bleeding, known as pseudomenstruation, may occur as a result of the sudden withdrawal of the mother's hormones at birth. It is not a result of trauma. Because the finding is normal, the pediatrician will not need to check the infant. Telling the mother that the finding is nothing to be concerned about is not the most appropriate option, because it is nontherapeutic.
A nurse who has just assisted in the delivery of a newborn infant is providing initial care to the infant. Which action should the nurse take to prevent heat loss by way of conduction in the infant? 1. Keeping the infant away from drafty areas 2. Keeping the infant away from cold windows 3. Warming the hands before touching the infant 4. Drying the infant as soon as possible after birth
(3) Conduction of heat away from the body occurs when a newborn comes in direct contact with an object that is cooler than his or her skin. Placing an infant on a cold surface or touching the newborn with cold hands or a cold stethoscope causes this type of heat loss. Convective heat loss occurs when heat is transferred to air surrounding the infant. Keeping the infant out of drafts and maintaining warm environmental temperatures help prevent this type of heat loss. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. An infant placed near a cold window loses heat by way of radiation. Heat loss by way of evaporation occurs when a wet surface is exposed to air. Drying the infant as soon as possible after birth and after bathing prevents this type of heat loss.
The mother of a newborn is upset because her newborn has a birthmark on the left side of the forehead. The mother, on being told that it is a nevus vasculosus (strawberry mark), asks the nurse whether the mark is permanent. What should the nurse tell the mother? 1. It is a permanent mark 2. It will need to be removed with surgery 3. It will disappear on its own by the early school years 4. It is nothing to be concerned about because it is so small
(3) Nevus vasculosus (strawberry mark) consists of enlarged capillaries in the outer layers of the skin. It is dark red and raised, with a rough surface, giving it a strawberry appearance. Usually located on the head, a nevus vasculosus may grow larger for 5 to 6 months but usually disappears by the early school years. No treatment is necessary.
A nurse calculates an infant's Apgar score 1 minute after birth and obtains a score of 8. Based on this finding, which action should the nurse take? 1. Notifying the infant's pediatrician 2. Administering oxygen to the infant 3. Recalculating the infant's Apgar score 5 minutes after birth 4. Attempting to stimulate the infant by rubbing the infant's back
(3) The nurse calculates the infant's Apgar score at 1 and 5 minutes after birth for rapid evaluation of early cardiopulmonary adaptation. If the score is between 8 and 10, no intervention is needed except for support of the infant's spontaneous efforts. If the score is between 4 and 7, the nurse gently stimulates the infant by rubbing his or her back and administers oxygen to the infant. A score between 0 and 3 indicates the need for resuscitation.
After a C-section delivery the obstetrician hands the newborn to the delivery room nurse. Prioritize the following actions (1) Place the newborn at the mother's breast (2) Take the newborn's temperature (3) Calculate the newborn's Apgar score (4) Wrap newborn in a warm blanket
(3, 2, 4, 1) The first assessment of the newborn, the Apgar score, is performed after birth (1 and 5 minutes after delivery) to ascertain the newborn's status and determine the need for resuscitation. This is the first priority. The nurse next takes the newborn's temperature, wraps the newborn in a warm blanket, and places him at the mother's breast. Other priority actions include suctioning the newborn's nares and drying the newborn. The nurse also places identification bracelets on both the newborn and the mother. In some settings, the father or partner also wear an id bracelet.
Which intervention does the nurse immediately implement for James Nicholas on the basis of his 1-minute Apgar score? 1. None 2. Preparing for neonatal resuscitation 3. Supporting spontaneous respiratory efforts 4. Gently stimulating the infant by rubbing his back and administering oxygen
(4) The Apgar scoring method is used for quick evaluation of the newborn infant's cardiorespiratory adaptation after birth. A 1-minute score of 4 to 7 means that the nurse should take measures to stimulate the infant, such as gently rubbing the infant's back, while administering oxygen. Resuscitation is necessary for scores of 0 to 3. For Apgar scores of 8 to 10, no action is needed except for continued observation and support of the infant's own spontaneous efforts.
Newborn James Nicholas is taken to the nursery for assessment and placed in the infant warmer while he is cleansed. His vital signs are stable, and he settles easily. Before taking the infant back to his mother, the nurse administers an injection of vitamin K. Which injection route and site are appropriate? 1. Intravenous 2. Subcutaneous, upper arm 3. Intramuscular, dorsogluteal muscle 4. Intramuscular, vastus lateralis muscle
(4) Vitamin K, when administered for the prevention of hemorrhagic disease in the newborn, is given intramuscularly in the vastus lateralis. It is never given as a subcutaneous injection, and intravenous vitamin K is only used in special situations, such as for a preterm infant who does not have any muscle mass to support injections. The dorsogluteal muscle is very small and poorly developed in newborns, and the sciatic nerve is much more prominent at this age. Additionally, the deltoid muscle of a newborn does not have enough mass for an injection.
Which precautions should the nurse take to prevent newborn abduction? Select all that apply. 1. Placing the newborn's crib close to the mother's door 2. Instructing the mother to carry the newborn to the nursery after feeding 3. Closing the hospital room door if the infant needs to be left unattended 4. Questioning unknown person(s) who are carrying large bags or packages 5. Ensuring that all health care personnel wear proper name (identification) badges
(4, 5) Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if no one is available to watch the newborn (the newborn is never left unattended). The nurse should monitor the environment closely and question any suspicious or unknown person, especially one carrying a large bag or package that could contain an infant.
