NEWBORN PASSPOINT

Following the admission assessment of a neonate born at 42 weeks of gestation the nurse documents which findings as normal? SATA

-3 vessel umbilical cord -Peeling skin on the feet -Absence of vernix caseosa -Cyanosis of the hands and feet

The nurse is caring for a family that is grieving the loss of their newborn which tokens of remembrance would be appropriate to provide?

-A picture of the newborn -The foot prints -a lock of hair -an invitation to an annual remembrance

The nurse must administer erythromycin ophthalmic ointment 0.5% to a neonate born 30 minutes ago. How should the nurse proceed? SATA

-Clean the eyes before administration -Put on gloves -Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the peri-orbital ridges -Spread the ointment from the inner canthus of the eye to the outer canthus -Wipe excess ointment from the eyes after waiting one minute

A nurse is assessing a newborn with the following findings: RR of 40 BPM HR of 145 BPM and a temp of 97.3 degrees Fahrenheit. Which are appropriate nursing interventions? SATA

-Double wrap the newborn with blankets -Place a hat on the newborn -Reduce the newborns exposure to drafts

The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of skin to skin care include which benefits? SATA

-Enhanced bonding -Improved physiologic stability -Decrease the length of stay in the neonatal intensive care unit -Improved breast-feeding

The nurse is assessing an hour old newborn. Which observations would the nurse note as being abnormal? SATA

-Expiratory Grunting -Temp of 97.4 -Nasal flaring

A graduate nurse is explaining to the nurse mentor how to assess newborn jaundice and the effects of phototherapy on a dark skin client. Which statement made by the graduate nurse need clarification? SATA

-I will carefully record the neonate intake of limiting fluids as helpful -The neonate will be irritable from the elevated bilirubin in the system

The nurse working on the mother baby unit teaches the client about the facilities measures to prevent infant abduction. what precautions does the nurse discuss? Select All that Apply

-Infant footprints and a color photograph are taken soon after birth -Only let Staff wearing an appropriate identification band transport your baby -Notify the staff about anyone who appears unusual

The nurse is demonstrating umbilical cord care to the client who recently gave birth. Which action should the nurse teach the client to perform?

-Keep the diaper below the umbilical cord -Only sponge bathe the neonate until the umbilical cord falls off -Allow the cord to be exposed to air

During the initial assessment of a newborn the nurse notes the presence of cephalohematoma, which is the primary nursing action? SATA

-Monitor for jaundice -Ensure frequent feedings -Monitor output closely

A nurse is caring for a full term neonate who is 24 hours old. Assessment findings include axillary temp of 96.8, apical heart rate of 188 bpm, and a RR of 48 bpm. The mother reports the neonate is lethargic when she tries to break-feed and looks like a rag doll. The mother also has a low grade fever pulse ox reveals saturation of 89% on room air and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? SATA

-Observe the neonate carefully, contact the physician and explain her suspicions of early neonatal sepsis -Provide blow by oxygen and monitor the neonate respiratory status -Inform the parents that she wants to monitor the neonate closely

What information would the nurse include in discharge instructions for post circumcision care to the parents of a neonate? SATA

-Parents must know that the neonate has voided -petroleum jelly or antibiotic ointment should be applied to the glands of the penis with each diaper change -The circumcision will require care for 2-4 days after discharge

The parents of a young infant are exhausted and frustrated because their infant has colic and cries constantly. What interventions should the nurse teach the parents to help console their infant? SATA

-Place the infant in a swing -Carry the infant in a carrier strapped to you -Offer the infant a pacifier

A nurse is completing a physical assessment of a neonate following birth, when completing musculoskeletal assessment which findings would indicate developmental dysplasia of the hip? SATA

-Positive Barlow test -asymmetrical leg skin folds

Which findings in a newborn would require the nurse to notify the primary care provider? SATA

-Positive Ortolani sign -Absence of MORO reflex

The newborn nurse has just received shift report about a group of newborns and is to receive another admission in 30 minutes. To provide the safest care and plan for the new admission the nurse should so which tasks in order from first to last? SATA

-Review notes from the shift report and prioritize all clients make rounds on the most critical -Move quickly from room to room and assess all clients -Log onto the clinical information system and determine if there are new prescriptions -Check the room to watch the new client will be admitted to and ensure all supplies and equipment are available

The nurse is discharging a newborn to home, which discharge instructions will a nurse give to the newborns parents? SATA

-Sponge bathe as needed until the umbilical cord falls off -Ensure that feedings occur every 3-4 hours -Place newborn in a rear facing carseat

During change of shift report, it was reported that a neonate was experiencing subcostal retractions. Identify where the nurse would expect to see the retractions.

-Under the rib cage

The nurse is caring for a post term newborn what interventions will the nurse include in the clients plan of care? Select all that apply

-encourage early feedings -Assess for respiratory distress -Assess for hypoglycemia -Double wrap the infant in blankets