OB: Ch. 18 Nursing Management of the Newborn

The nurse has completed the initial assessment and vital signs for an infant born at 12:00 p.m. The assessment and vital signs were completed at 1:30 p.m. What time will the nurse plan to complete the next set of vital signs?

2:00 p.m. The nurse needs to complete vital signs every half hour for the first 2 hours of life. This makes the other options incorrect.

When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, from first to last, will the nurse expect these characteristics disappear? All options must be used.

Pink coloration is lost. Respiratory effort decreases. Muscle tone decreases. Reflex irritability is noted. Heart rate decreases. The Apgar score is a method of evaluating a newborn's physical condition at 1 and 5 minutes after birth. Assessment is an indication of the newborn's overall central nervous system status. When the newborn experiences physiologic depression, the characteristics disappear in a predictable manner: first the pink coloration is lost, next the respiratory effort, then the tone, followed by reflex irritability, and finally the heart rate.

A newborn has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways?

Position the newborn on his side with his head slightly below his body; use a bulb syringe to clear his mouth. The infant needs to have bulb suction used to remove the secretions, the head should be held slightly lower than the body to facilitate use of gravity. Right after birth is not the time for the parents of the newborn to be instructed in how to suction their infant. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The remaining option is incorrect as it does not clear the infant's mouth of secretions.

When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do?

Take blood, using a heel stick, to check for hypoglycemia. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteryness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level with a heel stick. The infant described in the scenario does not need to be placed under a radiant warmer or have its temperature assessed with a thermal skin probe. The nurse does not rule out hypoglycemia in an infant by checking the mother's chart to see if she is diabetic or has other risk factors.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

The nurse is assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would the nurse apply to the surgical area?

petrolatum gauze dressing Immediately after the procedure, place a petrolatum gauze dressing, as prescribed by the primary care provider.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often?

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond?

pain administration may not be effective during the procedure The anesthetic block is not always effective. Not all providers use anesthetics prior to the procedure, and the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are not disadvantages to the procedure; they are advantages.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life. The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse should not conclude that the infant is in severe distress requiring immediate interventions for survival or has a congenital heart or respiratory disorder. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life.

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

A newborn has been taken to the nursery after birth. He has been cleaned in the labor and birth suite and is swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do?

Wear gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received?

"I will give him vitamin D supplements daily for the first 2 months of life." As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water.

The primapara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset?

"We'll turn the mobile on that's hanging above his head in his crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

A client expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse?

"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." The nurse will know that a newborn is adequately hydrated if he has 6 to 12 wet diapers a day. It is still within normal limits if the newborn has not passed meconium by 24 hours of age. Although urinating after feeding is common, it is not essential to ensure adequate hydration.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?

Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is .66 to 1 ounce (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

What is the most important thing the nurse can teach the family of a newborn to prevent abduction while the baby is in the hospital?

Check the identification badge of any health care worker before he or she takes the baby from the room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. Learning to recognize the baby's cry would be ineffective in the prevention of an infant abduction from the hospital because the baby may not be crying as it is carried out of the unit. Checking the name and number on the baby's identification bracelet would tell the family it is their baby, not if it is being abducted by someone who is not employed by the hospital.

The parent of a newborn asks what caused the bacterial infection ophthalmia neonatorum in the baby. The nurse correctly responds that ophthalmia neonatorum can be caused by which bacteria? Select all that apply.

Chlamydia Gonorrhea Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn.

A very healthy mother gave birth to a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take?

Instill antibiotic 0.5 percent erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5 percent erythromycin or 1 percent tetracycline eye drops. Although 1% silver nitrate drops were once used, it has not been shown to prevent chlamydial eye disease. One percent erythromycin and 0.5 percent silver nitrate are incorrect concentrations of these medications and should not be instilled into the eyes of the newborn. The nurse would not wait to see if the eyes show signs of irritation before completing eye care treatment on the newborn.

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex?

Moro The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity?

Moro reflex There are six activities or maneuvers that are evaluated to determine the newborn's degree of maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions Signs of respiratory distress in the newborn include tachypnea (respirations greater than 60 breaths/min, tachycardia (heart rate greater than 160/beats/min, nasal flaring, chest retractions, and generalized cyanosis. Blue hands and feet , referred to as acrocyanosis, is caused by poor peripheral circulation not respiratory distress.

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which method should the nurse use to do this?

Observe chest movement. Respirations are counted by observing chest movement. Reflex irritability may be evaluated by observing response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Heart rate is typically determined by auscultation with a stethoscope but may also be obtained by observing and counting the pulsations of the umbilical cord at the abdomen, if the cord is still uncut. Muscle tone is evaluated by observing resistance to any effort to extend the newborn's extremities.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Beside placing the infant on a firm sleep surface, what should the nurse tell the mother to do? Select all that apply

Place the infant on his or her back. Not allow anyone to smoke around the infant The newborn or infant should be placed on her back to sleep on a firm sleep surface. Sleeping on the stomach (prone) may limit the newborn's ability to move her head, which increases the chance of suffocation. Parents should also prevent exposure to tobacco smoke.

The infant's temperature is 97.2° F (36.2° C) axillary an hour after birth. Which intervention is appropriate for the nurse?

Place the infant under a radiant warmer or in a heated isolette. If the infant has a low temperature of 97.2° F (36.2° C), the nurse should place the infant in a radiant warmer or in an isolette. Once the infant has a core temperature of greater than 97.7° F (36.5° C), the nurse will double bundle and recheck the temperature in 30 minutes. If an infant has a temperature that is considered low the nurse would not take the infant to its mother for bonding or administer a warm bath. The nurse would initiate interventions to stabilize the infant's temperature within normal range.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

Which newborn neuromuscular system adaptation would the nurse not expect to find?

an extrusion reflex at 9 months of age An extrusion reflex usually disappears around 4 months of age. A positive Babinski reflex can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.

A nurse is assessing a newborn's gestational age, When determining neuromuscular maturity, which parameters would the nurse assess? Select all that apply.

arm recoil scarf sign Arm recoil and the scarf sign are used to evaluate neuromuscular maturity. Physical maturity indicators include skin, lanugo, plantar surface, breast, eye-ear, and genitals

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is:

at least 24 hours after birth. This screening needs to be done on an infant 24 hours to 7 days after birth. The timing of the screening test is determined by the age of the infant, not the number of feedings.

Which vital sign is not routinely assessed in a term, healthy newborn with an Apgar score of 9?

blood pressure Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye A red bumpy area noted above the right eye is a hemangioma and needs further investigation to determine whether the hemangioma could interfere with the infant's vision. They may grow larger during the first year then fade and usually disappear by age 9. Stork bites or salmon patches and blue or purple splotches on buttocks (Mongolian spots) are common skin variations and are not concerning. Erythema toxicum, seen as a fine red rash over the chest and back, is also a normal skin variant that will disappear withn a few days.

When educating clients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction?

cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Posting security policies, placing monitors on the babies, and educating the staff about infant abduction profiles are not the most essential elements of an effective abduction prevention plan.

A new mother asks the nurse why her baby's back and groin have a red and raised rash. The nurses uses which term to correctly identify this condition?

erythema toxicum Erythema toxicum is a rash of unknown cause, with pink papules and superimposed vesicles. It appears within 24 to 48 hours after birth and resolves spontaneously in a few days. Acrocyanosis is a blue color of the hands and feet appearing in most infants at birth. Acrocyanosis may persist for 7 to 10 days. Yeast is a fungal infection caused by Candida albicans; it usually manifests in the groin. The rash of C. albicans is excoriated and does not disappear without treatment. The presentation described in this scenario is not consistent with that of mumps.

On an Apgar evaluation, how is reflex irritability tested?

flicking the soles of the feet and observing the response Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline Newborns do not usually follow past the midline until 3 months of age. They do not tear.

One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection?

handwashing Educate parents about appropriate home measures that will prevent infections, such as practicing good handwashing, keeping the newborn well hydrated, avoiding bringing the infant into crowds, observing for early signs of infection, and keeping pediatrician appointments for routine visits.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet

Infants receive vitamin K within the first hour after birth. What is the rationale for administering the vitamin?

helps in formation of clotting factors, to prevent bleeding Vitamin K is necessary in the formation of certain clotting factors. The newborn is lacking in vitamin K, and the only method for the infant to receive it is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut, so the infant cannot manufacture vitamin K. Vitamin K is not administered to give the infant better eyesight, nor is it used to help fight infections.

The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge?

hep B Hep B is the vaccination against hepatitis B recommended by the CDC. All the other immunizations are recommended to be started at 2 months of age

The nurse is discharge teaching the parents of a newborn baby girl. The nurse knows that it is important to teach them about diarrhea and dehydration. When should the parents notify the primary care provider about diarrhea in the newborn?

if the infant has more than two episodes of diarrhea in one day Diarrhea is defined as frequent stools with high water content. Because newborns dehydrate quickly, it is important for parents to notify the care provider if the newborn has more than two episodes of diarrhea in one day.

A nurse is preparing to administer vitamin K to a newborn. The nurse would administer the drug by which route?

intramuscularly in the thigh The American Academy of Pediatrics recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a one month period. It is not given intravenously or topically. Erythromycin or tetracycline is used for eye prophylaxis.

A nurse is preparing to administer Vitamin K to a newborn. The nurse would adminsiter the drug:

intramuscularly. The American Academy of Pediatrics recommends that vitamin K be administered to all newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg. An oral vitamin K preparation is also being given to newborns outside the United States, but at least three doses are needed over a one month period. It is not given subcutaneously or intravenously.

While teaching a student, the nurse should include which signs and symptoms to recognize hypoglycemia in the neonate? Select all that apply.

jitteriness poor feeding tachypnea Signs and symptoms of hypoglycemia in newborns include jitteriness or tremors, exaggerated Moro reflex, irritability, lethargy, poor feeding, listlessness, apnea, respiratory distress including tachypnea, and a high-pitched cry.

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the primary care provider as they indicate potential problems. Which signs might indicate a problem? Select all that apply.

labored breathing generalized cyanosis flaccid body posture During the initial newborn assessment, the nurse should look for signs that might indicate a problem, including nasal flaring, chest retractions, grunting on exhalation, labored breathing, generalized cyanosis, abnormal breath sounds, abnormal respiratory rates (less than 25 or more than 60 breaths per minute), flaccid body posture, abnormal heart rates (less than 100 or more than 160 beats per minute), or abnormal size.

The nurse measures a newborn's temperature immediately after birth and finds it to be 99° F (37.2° C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

lack of subcutaneous fat Insulation, an efficient means of conserving heat in adults, is not as effective in newborns because they have little subcutaneous fat to provide insulation. Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism as well as regulating body temperature similar to that of a hibernating animal. Other ways newborns are able to increase their metabolic rate and produce more heat include kicking and crying.

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse?

lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

A nurse is conducting a physical examination of a newborn. The nurse documents which finding as within normal parameters? Select all that apply.

length of 54 cm weight of 3,300 grams temperature of 98.6° F (37° C) Typical newborn findings include length of 45 to 55 cm, weight of 2,700 to 4,000 grams, head circumference of 33 to 35 cm, chest circumference of 30 to 33 cm, temperature of 97.7° F to 99.5° F (36.5° C to 37.5° C), and apical pulse rate of 120 to 160 beats/minute.

Discharge teaching is an important part of the labor and birth room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the primary care provider. What are the parameters for calling the care provider in regards to an infant's temperature?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C) Temperatures of less than 97.7 ° F (36.5° C) or greater than 100 ° F (37.8° C) should be reported to the primary care provider.

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:

milia. Milia are the tiny white pinpoint papules of unopened sebaceous glands frequently found on the newborn's nose. Lanugo is the fine downy hair that covers the newborn's shoulders, back, and upper arms. Vernix caseosa is the thick white substance that provides a protective covering of the skin of the fetus. The harlequin sign refers to a transient phenomenon in which a newborn appears red on the dependent side of the body and pale on the upper side when lying on his or her side.

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding?

nevus flammeus Nevus flammeus, also called a port wine stain, may be associated with structural malformations, bony or muscular overgrowth, and certain childhood cancers and should be monitored with periodic examinations. Erythema toxicum is a benign rash that resembles flea bites. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Nevus vasculosus is also called strawberry mark and is a benign capillary hemangioma that tends to resolve by age 3 without treatment.

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics

When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect?

pseudomenstruation, a normal finding Pseudomenstruation is seen when a newborn female has a small amount of pinkish discharge. It comes from the withdrawal of maternal hormones and is a normal finding.

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?

right upper abdominal quadrant A thermistor probe is taped to the newborn's abdomen, usually in the right upper quadrant. This allows for position changes without having to readjust the probe.

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment?

rooting The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited?

rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn

A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This movement is known as which reflex?

rooting reflex The rooting reflex is demonstrated when, in response to the newborn's cheek being stroked, the infant turns her head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn's cheek, the reflex causes the baby to turn toward the breast. The extrusion reflex is demonstrated when a newborn extrudes any substance that is placed on the anterior portion of the tongue; this reflex prevents the swallowing of inedible substances. The Moro reflex is demonstrated when, in response to a sudden backward head movement, the newborn abducts and extends arms and legs, then swings the arms into an embrace position and pulls up the legs against the abdomen. The Babinski reflex is demonstrated when the sole of a newborn's foot is stroked in an inverted "J" curve from the heel upward and the newborn fans the toes in response (positive Babinski sign).

All of the following are ways the nurse can encourage bonding between the parents and the newborn except:

telling the mother that the best way to bond with her baby is to breastfeed. Modeling behavior such as talking to the newborn will aid in bonding. Being able to observe parents as they provide care to their newborn will give new parents confidence. Asking their permission to pick up the newborn will give them a sense of ownership. Although breastfeeding is an excellent way for a mother to bond with her baby, it is not the only way and it is not necessarily the best way

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot The calcaneus is the bone of the heel. A heel stick should not be done on the flat part of the foot or heel, but instead on the lateral aspect of the foot, where the fat pads are.

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm For a term infant, expected weight is 2500 to 4000 g; length is 19 to 21 inches (48 to 53 cm); head circumference is 33 to 35 cm; and chest circumference is 30.5 to 33 cm.

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.

A nurse is discharge teaching with a group of new parents before they are discharged home with their infants. One couple inquires as to why they need to place their new baby on its back to sleep. What is the nurse's best response?

"Research has shown that placing an infant on its back to sleep reduces the risk for SIDS."

When the nurse performs the Ortolani maneuver, what should occur? Select all that apply.

The newborn should be in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure. The newborn should be in the supine position. The nurse will flex the hips and knees to 90 degrees at the hip, then will attempt to abduct the hips 180 degrees while applying upward pressure. A "click" or a "cluck" should not be heard when the legs are abducted.

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:

acrocyanosis. Acrocyanosis is a blue tint to the hands and feet of newborns during the first few days of life. Acrocyanosis is a normal finding and is not indicative of a potential for respiratory distress, poor oxygenation, or cold stress.

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?

the first 6 months Both the AAP and the ADA recommend breastfeeding exclusively for the first 6 months of life. After 6 months, breastfeeding does not need to be exclusive, but it should be continued until 12 months

With a hepatitis B (HbsAG) positive mother, what should the newborn receive?

the hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth If a mother has hepatitis B or is suspected of having hepatitis B, the newborn should be bathed and then should receive 1 dose of the hepatitis B vaccine and 1 dose of the hepatitis B immuoglobulin within 12 hours of birth.

The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding?

two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein.

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age?

10% Newborns typically lose approximately 10% of their initial birth weight by 3 to 4 days of age secondary to the loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life.

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be?

11 The normal infant heart rate should be greater than 100 bpm. Twelve is an acceptable heart rate in an infant, but it is not the minimally accepted heart rate.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

What is the expected range for respirations in a newborn?

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein's pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.

A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110 bpm; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which score would be the total Apgar score for this newborn?

8 The heart rate of 110 bpm, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8.

A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated?

Babinski reflex The Babinski reflex is demonstrated when the sole of a newborn's foot is stroked in an inverted "J" curve from the heel upward and the newborn fans the toes in response (positive Babinski sign). The rooting reflex is demonstrated when, in response to the newborn's cheek being stroked, the infant turns her head in that direction. This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn's cheek, the reflex causes the baby to turn toward the breast. The extrusion reflex is demonstrated when a newborn extrudes any substance that is placed on the anterior portion of the tongue; this reflex prevents the swallowing of inedible substances. The Moro reflex is demonstrated when, in response to a sudden backward head movement, the newborn abducts and extends arms and legs, then swings the arms into an embrace position and pulls up the legs against the abdomen.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein's pearls. Epstein's pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

Which nursing diagnosis would be highest in priority for a newborn?

Ineffective airway clearance related to mucous obstruction. Any airway clearance or obstruction issue is the highest priority for nursing interventions. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn. This rash is most likely is erythema toxicum, also known as newborn rash.

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply.

Mongolian spots short, creased neck swollen genitals Mongolian spots, swollen genitals in the female newborn, and a short, creased neck are normal findings in a newborn. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Female babies may have swollen genitals as a result of maternal estrogen. The newborn's neck will appear almost nonexistent because it is so short. Creases are usually noted. Enlarged fontanelles are associated with hydrocephaly; congenital hypothyroidism; trisomies 13, 18, and 21; and various bone disorders such as osteogenesis imperfecta. Low-set ears are characteristic of many syndromes and genetic abnormalities such as trisomies 13 and 18 and internal organ abnormalities involving the renal system.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply.

Take warm-to-hot showers to encourage milk release. Express some milk manually before breastfeeding. Apply warm compresses to the breasts prior to nursing. To relieve breast engorgement in the client, the nurse should educate the client to take warm-to-hot showers to encourage milk release, express some milk manually before breastfeeding, and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions—sitting up and then lying down. The breasts should be massaged from under the axillary area, down toward the nipple.