Maternal Newborn Postpartum 2

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar creases

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?

At 1 minute after birth and 5 minutes after birth

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

Cyanosis Tachypnea Retractions Audible grunts

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings should the nurse most specifically expect to note in the infant? Select all that apply.

Failure to thrive Coughing, wheezing, and short periods of apnea

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment?

Heart rate 130 beats/minute, respirations 46 breaths/minute

An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply.

Irritability Failure to thrive Choking with feeding Spitting up and regurgitation

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn?

Oxygen supplementation and suctioning

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider (PHCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply.

Protect defect from trauma. Maintain a thermoneutral environment. Assess for associated birth defects such as cleft palate.

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which assessment findings should the nurse expect to note in the neonate? Select all that apply.

Tremors Tachycardia Exaggerated startle reflex

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my husband is not here."

The mother of a preterm newborn is comparing the appearance of her preterm baby to the nearby full-term babies. She asks why her baby's skin appears so different. What is the best response for the nurse to provide?

"A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat."

Which is considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of the hands and feet

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?

Notify the pediatrician.

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route?

Phytonadione (vitamin K)

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action?

Make a loud, abrupt noise to startle the newborn.

The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction?

"Begin with the eyes and face."

The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions?

"I need to fold the diaper above the cord to prevent infection."

The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide?

"The injection is extremely important to prevent bleeding in your baby."

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results?

Indicates the presence of maternal infection

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic.

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?

Elevates the gastrostomy tube

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10

Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply.

10 to 20 mL is the stomach capacity of a 1-day-old newborn 90 to 150 mL is the stomach capacity of a 1-month-old infant

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority?

Administer oxygen via resuscitation bag to the newborn infant.

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn?

Assessing skin integrity and fluid status of the newborn

The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented?

Document the finding in the electronic health record.

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take?

Document the findings.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

Document the findings.

The nurse is reviewing the record of a newborn infant in the nursery and notes that the primary health care provider (PHCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?

Edema resulting from bleeding below the periosteum of the cranium

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.

Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement?

Place a warm blanket on the examining table before placing the newborn on the table.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.

A soft and flat anterior fontanel A triangular-shaped posterior fontanel

The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority?

Blood glucose levels

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction?

"I need to breast-feed, especially for the first 6 weeks postpartum."

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?

"Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside?

A bottle of sterile normal saline

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother?

Continue to breast-feed every 2 to 4 hours.

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions?

The mother bathes the newborn infant after a feeding.

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine?

The newborn requires some resuscitative interventions.

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding?

Finding 2 vessels may indicate an increased risk for other congenital anomalies.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

"Foods and fluids that will increase urine alkalinity should be consumed."

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply.

A copper-colored skin rash Mucopurulent nasal drainage (snuffles)

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4400 g. The nurse determines that this infant may be at risk for which complications? Select all that apply.

Hypoglycemia Fractured clavicle Congenital heart defect

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply.

Irritability Constant crying Difficult to comfort

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be appropriate?

Notify the primary health care provider (PHCP).

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low set. Which nursing action is most appropriate?

Notify the primary health care provider.

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma?

Palpate the clavicles for a fracture.

The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply.

Pat the baby dry gently Support the newborn's body during the bath. Make sure that the room temperature is 75º F (23.9º C). Cleanse one body area at a time keeping other body areas covered.

The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant?

Periodic well-baby examinations

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference?

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.

The nurse is caring for a term newborn. Which assessment finding should alert the nurse to suspect the potential for jaundice in this infant?

Presence of a cephalhematoma

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.