Module 7 practice

Neonate born at 37 weeks with HR 105, strong cry, some flexion of extremities, has acrocyanosis. What Apgar score should the nurse assign at 1 minute?

8

Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A. Cephalohematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D. Subdural hematoma, which can result in lifelong damage

A Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.

Which is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? A. Warming the newborn B. Clamping the umbilical cord C. Assessing maternal bleeding D. Monitoring expulsion of the placenta

A Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. The cord may be left intact until the newborn's temperature has stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother, the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

The nurse is providing care to an infant at 24 hours old. Upon assessment, the nurse observes milia on the newborn's nose. What is the nurse's next action? A. Document the findings in the newborn's chart. B. Ask another nurse to confirm the findings. C. Assess the mother for the presence of milia. D. Contact the pediatric health care provider.

A Milia are common tiny white raised areas, generally located on an infant's nose or face. They are self-resolving, requiring no immediate medical attention. Teach the mother that the milia will generally resolve in a month. Only documentation is required for this client.

Which assessment finding in a newborn of 33 weeks gestation alerts the nurse to notify the health care provider? A. Flaring nares B. Acrocyanosis C. Heartbeat of 140 bpm D. Respirations of 40 bpm

A Preterm neonates are prone to respiratory distress; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and to increase oxygen intake. Acrocyanosis is not related to respiratory distress but it is caused by vasomotor instability ; this is an expected finding in the newborn. A respiratory rate of 40 breaths/min is expected as well as heartbeat of 140 bpm.

Which instructions would the nurse give the mother of a newborn boy who is being discharged 4 hours after having had a circumcision? A. Apply the diaper loosely for several days. B. Give the newborn a crushed baby aspirin if there is irritability. C. Check for bleeding at circumcision site every 2 hours during the first day home. D. Call practitioner whitish drainage around the glans.

A The diaper is applied loosely to prevent pressure on the circumcised area because the glans remains tender for 2 to 3 days. Aspirin may prolong clotting and is contraindicated in children because of its relationship to Reye syndrome. The caregiver should check for bleeding every hour for the first 12 hours after the circumcision. Whitish exudate around the glans is expected and does not indicate an infectious process.

Five minutes after birth, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 bpm; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?

5

When calculating the Apgar score for a newborn, which would the nurse assess in addition to the heart rate? A. Muscle tone B. Amount of mucus C. Degree of head lag D. Depth of respirations

A The five areas that are assessed when the Apgar score is calculated are heart rate, respiratory effort, muscle tone, reflex irritability, and color. The rate of respirations, not depth is assessed.

The nurse is providing care to an infant born 2 minutes ago with an Apgar of 8 at one minute. What nursing actions must the nurse include in the newborn's plan of care over the next 30 minutes? (Select all that apply.) A. Temperature B. Heart rate C. Apgar score D. Blood pressure E. Blood glucose

ABC Temperature indicates if the newborn is thermodynamically stable. Heart rate supports circulation status of the newborn. The first Apgar score is performed at 1 minute and the second at 5 minutes of age. Blood pressure and blood glucose are not indicated unless the newborn appears somehow compromised.

The nurse is providing care to a 1-hour-old infant. An assessment of gestational age is performed and the nurse estimates the age at 39 to 40 weeks. What findings will the nurse document in the infant's chart? (Select all that apply.) A. Vernix in the creases of the neck B. Lanugo covering the entire back C. Creases over the anterior 1/3 of the foot D. Breast tissue less than 0.5 cm in both breasts E. Labia majora covers the labia minora.

AE Vernix in neck creases and the labia majora covering the labia minora are signs of a term infant. Lanugo covering the back, foot creases anterior third and breast tissue less than 0.75 cm are assessment findings associated with preterm infants.

Which finding indicates the development of a complication from bilateral cephalohematomas? A. Urine output B. Skin color C. Glucose level D. Rooting/sucking reflex

B Cephalohematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice or yellowing of the skin may result. Urine output, glucose level, and the rooting/sucking reflex are not affected by a cephalohematoma.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Hair located on the back of the shoulders D. Red patches on the cheeks and trunk

B Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Lanugo is fine hair located on the back and shoulders. It is a normal finding. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.

The nurse is preparing to bathe a neonate born at 30 weeks gestation. Which practices ensure the infant's safety? SATA A. Gives the neonate a daily warm-water bath B. Immerses the neonate fully except the head in the tub C. Measures the body temperature within 2-4 hours before giving the bath D. Removes the vernix completely from neonate's skin while giving the bath E. Uses cleansing agents with neutral pH and minimal dyes while giving the bath

BCE A neonate born before 32 weeks gestation is known as a preterm infant. Immersing the neonate's head in water can increase the risk for respiratory depression. The neonate's body temperature should be stable 2-4 hours before giving the initial bath. The nurse monitors body temperature before giving a bath. Cleansing agents with neutral pH and minimal dyes reduce skin irritation, so these are used when bathing the neonate. The nurse would give a warm-water bath every second or third day, not daily, to prevent hypothermia. Removing vernix completely during the initial bath can alter thermoregulation in a neonate.

Which statements made by the parent indicate further teaching is needed about the care of circumcision for a 3-day-old newborn? Select all that apply. One, some, or all responses may be correct. A. "I will avoid using any baby wipes until the penis has healed." B. "My baby should have at least four wet diapers in a 24-hour period." C. "I can expect a yellow exudate to form over the penis after 24 hours." D. "I can wash the circumcised area with soap and water if it becomes soiled." E. " I should apply the diaper snugly over the penis to help prevent bleeding."

BDE Baby wipes should be avoided until the site is healed because they may contain alcohol. A yellow exudate is normal after 24 hours and should not be wiped off. A 3-day-old newborn should have at least six to eight wet diapers within a 24hour period. The circumcised area should be washed with warm water only, and the diaper should be applied loosely over the penis to prevent pressure on the circumcised area.

The nurse is considering best practice to promote best practice to promote skin-to-skin contact. During which of these periods should the nurse place the baby on the maternal chest for STS? A. 1st period of reactivity B. 1st period of inactivity C. 2nd period of reactivity D. 3rd period of inactivity

C

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. The head is really funny looking." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."

C Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

C Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

C With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? (Select all that apply.) A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis E. Chlamydia F. Hepatitis B

CE Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, D, and F.

Which of these assessment findings should the nurse consider a sign of prematurity in a neonate? A. Open anterior fontanelle B. Present Simian crease C. See-saw breathing is present D. Scant creases on the sole of the feet

D

Which of these assessment findings should the nurse consider to be a sign of tern gestation in a neonate? A. Closed posterior fontanelle B. Cremasteric reflex is present C. Heavy vernix present D. Labia majora covers the minora

D

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

D In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.

One hour following a normal vaginal delivery, a newborn infant's axillary temperature is 96° F/35.6 C, the lower lip is shaking, and when the nurse assesses for a Moro reflex, the baby's hands shake. Which nursing action should the nurse take first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

D This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.