OB PrepU 18 Nursing Management of the Newborn

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? Complete the hearing test. Provide hepatitis B vaccination. Administer vitamin K. Perform the newborn screening.

Administer vitamin K. Explanation: Vitamin K is used to promote blood clotting in the newborn and is priority to administer to the newborn. The hearing test, hepatitis B vaccine, and newborn screening should all be completed prior to discharge.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 month after discharge After the newborn has completed the antibiotic therapy 1 day after birth Before discharge from the hospital

After the newborn has completed the antibiotic therapy Explanation: It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Reduced risk of penile cancer Fewer complications than if done later in life Lower rate of urinary tract infections Anesthetic may not be effective during the procedure

Anesthetic may not be effective during the procedure Explanation: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus 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 advantages to the procedure.

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client? Administer analgesics for pain on a scheduled basis. Apply petroleum gauze to the penis with each diaper change. Monitor the amount of bleeding and chart it. Position the infant on his side for comfort.

Apply petroleum gauze to the penis with each diaper change. Explanation: When a newborn is circumcised using a Plastibell, petroleum gauze is not used since the Plastibell protects the glans of the penis until it is healed. All other interventions are appropriate.

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? Ask to see the woman' hospital identification badge. Ask the woman to bring the infant back when the doctor finishes the examination. Call the nursery to confirm the doctor does indeed need this infant at this time. Ask how long the infant will be gone since her next feeding is in 30 minutes.

Ask to see the woman' hospital identification badge. Explanation: The nurse will not release an infant to anyone who does not have a hospital photo ID that matches the security color or code for the hospital, indicating that they are authorized to transport infants. Asking the woman to bring the newborn back, calling the nursery, or determining how long the newborn will be gone do not address the security issue.

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take? Assess the bilirubin level. Proceed with the discharge. Assist the mother to feed the newborn. Notify the health care provider.

Assess the bilirubin level. Explanation: If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time.

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? Follow the nap and feeding schedule used at home. Ensure the caregivers bring blankets and toys from home. Be consistently attentive to the infant's basic needs. Allow the infant opportunities to self-soothe.

Be consistently attentive to the infant's basic needs. Explanation: To help the infant develop a sense of trust, the nurse will consistently meet the infant's needs through feedings, holding the infant, and keeping the infant dry. Following the same schedule as at home or allowing security items (blankets, favorite stuffed animal) may help provide comfort, but will not facilitate building trust. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his/her needs.

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn. Administer an oral dose of vitamin K to the newborn. Assume that the parents refused this medication for their infant. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Explanation: Vitamin K is given IM shortly after birth and, if this medication is not documented, the nurse in the newborn nursery must inquire if the medication was given. Vitamin K is given IM, not oral. A nurse can never assume that a required medication was refused just because it was not documented. Also, the nurse would not give the medication without inquiring to see if it had been administered but not documented.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Assess for pain source. Place child in a radiant warmer. Assess the baby's temperature. Check blood glucose.

Check blood glucose. Explanation: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Send a family member to accompany the infant when leaving the room. Provide a list of approved visitors who came spend time with the infant. Check the name on the baby's identification bracelet. Check the identification badge of any health care worker before releasing baby from room.

Check the identification badge of any health care worker before releasing baby from room. Explanation: 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. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: vernix caseosa. milia. lanugo. harlequin sign.

milia. Explanation: 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 Ballard scoring system evaluates newborns on which two factors? body maturity and cranial nerve maturity skin maturity and reflex maturity physical maturity and neuromuscular maturity tone maturity and extremities maturity

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

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Birth trauma noted on left upper outer thigh. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Mottling noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh.

Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Explanation: A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? Cooperation by the parents with the hospital policies Use of cameras at all doors Use of pass codes onto the unit Use of monitor attached to babies

Cooperation by the parents with the hospital policies Explanation: 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. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Notify the primary care provider if it appears red and sore. Cleanse the glans daily with alcohol. Soak the penis daily in warm water. Cover the glans generously with petroleum jelly.

Cover the glans generously with petroleum jelly. Explanation: Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? Dry the newborn and place it skin-to-skin on mother. Swaddle the infant and place in the bassinet. Assess the newborn's glucose level. Complete a full head-to-toe assessment.

Dry the newborn and place it skin-to-skin on mother. Explanation: Thermoregulation is priority immediately following delivery and is best achieved by keeping the newborn warm and dry. This can be accomplished by drying the newborn and placing it skin-to-skin with the mother. The newborn should be dried before being swaddled and placed in the bassinet. A complete assessment needs to be done within 2 hours of delivery and glucose isn't routinely assessed.

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate? Urge the parent to prop the bottle for the rest of the feeding. Encourage the parent to burp the newborn to get rid of air. Suggest the parent stop the feeding because the newborn is full. Instruct the parent to stop feeding for a few minutes and then restart.

Encourage the parent to burp the newborn to get rid of air. Explanation: Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent fussiness by burping them frequently throughout the feeding. Therefore, the best suggestion would be to have the parent burp the newborn. The newborn may or may not be full; the newborn may still be hungry but excess air in the stomach is making the newborn fussy. Feeding is a time for closeness. Propping a bottle interferes with bonding and increases the risk of choking and other problems. Stopping the feeding and then restarting it would do nothing to help alleviate the swallowed air and may contribute to more air being swallowed.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? stork bites congenital dermal melanocytosis milia Epstein pearls

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

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Evaporative Radiating Convective Conductive

Evaporative Explanation: Evaporative heat loss occurs with the evaporation of fluid from the infant.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Perform a 3-minute surgical-type scrub. Wear clean gloves. Use infection transmission precautions. Clean hands with a betadine scrub.

Explanation: 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 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? Place the newborn's buttocks in warm water after each void or stool. Expose the newborn's bottom to air several times a day. Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area.

Expose the newborn's bottom to air several times a day. Explanation: 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.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Feeding the infant more formula whenever she begins to fuss Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant's back

Feeding the infant more formula whenever she begins to fuss Explanation: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Gently patting or stroking the infant's back Feeding the infant more formula whenever she begins to fuss Swaddling the infant before returning to the crib Rocking and talking to the infant

Feeding the infant more formula whenever she begins to fuss Explanation: Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.

Parents are taking home their second child. They also have a 2-year-old at home. The nurse would anticipate which behavior by these parents? Only questions specific to breastfeeding General questions about different aspects of newborn care Confidence since they have another child already No questions of the nurse

General questions about different aspects of newborn care Explanation: Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? Place the infant under a radiant warmer. Help the mother provide skin-to-skin (kangaroo) care. Place a second stockinette on the baby's head. Administer a warm bath with temperature slightly higher than usual.

Help the mother provide skin-to-skin (kangaroo) care. Explanation: The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Identify the newborn. Administer the medication. Determine the newborn's weight. Assess the newborn for bleeding.

Identify the newborn. Explanation: The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Using a 21-gauge needle Injecting at a 45-degree angle Injecting 1cc of medication Injecting the medication into the vastus lateralis

Injecting the medication into the vastus lateralis Explanation: Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Inspect the clamp to insure that it is tightly closed and applied correctly. Clean the cord with soap and water, as oozing of blood is a common finding. Remove the clamp and replace with another one just above the old one. Notify the doctor to come suture the site of the bleeding.

Inspect the clamp to insure that it is tightly closed and applied correctly. Explanation: Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? This is an abnormal finding and needs to be reported immediately. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). If the fontanel (fontanelle) feels full, then this is normal.

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). Explanation: Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel (fontanelle). The fontanel (fontanelle) should not be bulging under any circumstance in a newborn.

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

Moro Explanation: The Moro reflex is also known as the startle reflex. When the infant is startled he or she extends the 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 assessment 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? popliteal angle Moro reflex square window scarf sign

Moro reflex Explanation: There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular 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 is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as do the infant's forehead and nose. Which action should the nurse take next? Initiate phototherapy. Obtain a transcutaneous bilirubin level. Prepare the infant for an exchange transfusion. Draw blood for a metabolic panel.

Obtain a transcutaneous bilirubin level. Explanation: Following visual identification of jaundice, the blood level of circulating bilirubin needs to be measured either by a transcutaneous bilirubin meter or a blood draw for a bilirubin level. Until the level of bilirubin in the blood is known to be elevated, neither phototherapy nor an exchange transfusion would be implemented. A metabolic panel is not useful in determining the level of neonatal jaundice.

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? Moro sucking rooting tonic neck

rooting Explanation: 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.

All of the following are ways the nurse can encourage bonding between the parents and the newborn except: asking the parents' permission to pick up the newborn. talking to the newborn in front of the parents. encouraging parents to provide care while the nurse is there to observe them. telling the mother that the best way to bond with her baby is to breastfeed.

telling the mother that the best way to bond with her baby is to breastfeed. Explanation: 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.

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? every other day once a week two or three times per week once a day

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

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 30 minutes after birth, in the birthing area within the first 2 to 4 hours, when the newborn reaches the nursery 24 hours after the newborn's birth prior to the newborn being discharged

within the first 2 to 4 hours, when the newborn reaches the nursery Explanation: 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 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? Obtain the temperature orally. Place electronic temperature probe in the midaxillary area. Obtain the temperature rectally. Tape electronic thermistor probe to the abdominal skin.

Place electronic temperature probe in the midaxillary area. Explanation: 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 nurse removes and discards a newborn's diaper before placing the newborn on the scales for a daily weight. The nurse realizes there are no clean diapers at the scale. The supply closet is located down the hallway. What will the nurse do? Go get another pack of diapers from the supply closet to place at the scales. Wrap the newborn in a blanket and carry the newborn to get another diaper. Place newborn in the bassinet and cover with blanket while obtaining diapers. Take a diaper from the newborn next in line to be weighed.

Place newborn in the bassinet and cover with blanket while obtaining diapers. Explanation: The nurse will cover the newborn to maintain temperature and place the infant in the bassinet while obtaining more diapers. The nurse would not leave to newborn on the scales and walk away, because the newborn could fall off the scale. Current policy prevents the nurse from carrying the newborn while going to the supply closet to obtain more diapers because this is a fall risk or safety issue. Infection control measures dictate that there is no sharing of supplies between newborns.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action? Allowing the mother to cut the cord of the newborn. Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. Wrapping the newborn in a towel and placing it on the mother's abdomen. Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Explanation: Skin-to-skin (kangaroo) care involves placing the newborn skin-to-skin with the mother and covering the newborn and mother with a light blanket. It is recommended that the newborn be placed in a diaper prior to being placed on the mother's chest for bonding.

Which statement is false regarding bathing the newborn? The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves. Mild soap should be used on the body and hair but not on the face. Bathing should not be done until the newborn is thermally stable.

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

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 infant requires immediate and aggressive interventions for survival. The infant probably has either a congenital heart defect or an immature respiratory system. The infant is adjusting well to extrauterine life.

The infant is experiencing moderate difficulty in adjusting to extrauterine life. Explanation: 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 7 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.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? The newborn's blood glucose will remain above 50 mg/dl The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn will be correctly identified prior to separation from the parents. The newborn will experience no bleeding episodes lasting more than 5 minutes.

The newborn will experience no bleeding episodes lasting more than 5 minutes. Explanation: Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? Newborn's toes curl over the nurse's finger. Newborn makes stepping motion. Toes fan out when sole of foot is stroked. Newborn throws arms outward and flexes knees.

Toes fan out when sole of foot is stroked. Explanation: The Babinski sign is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.

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 microwave ovens to warm the chilled milk. Use any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. Explanation: 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.

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? Using a bulb syringe, suction the mouth then the nose. Suction the nose first and then the mouth with a bulb syringe. Place the newborn on its stomach with the head down and gently pat its back. Suction the mouth and then the nose with a suction catheter.

Using a bulb syringe, suction the mouth then the nose. Explanation: A bulb syringe is used initially to suction secretions from a newborn's mouth and nose, starting with the mouth so the newborn does not aspirate the mucus into its lungs. Suctioning the nose first may stimulate the newborn to gasp or cry and this may lead to aspiration. A suction catheter is only used if the bulb syringe cannot manage all the secretions. Patting the newborn on the back will not clear out all the oral secretions.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? Any time prior to discharge Within 72 hours Within 12 hours Within one hour

Within one hour Explanation: Within the first hour after birth, an antibiotic ointment must be placed in the newborn's eyes to prevent ophthalmia neonatorum, a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia.

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: poor oxygenation. potential for respiratory distress. acrocyanosis. cold stress.

acrocyanosis. Explanation: 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 infant has Apgar scores of 7 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding? severe distress and absolute need of resuscitation adjusting to extrauterine life predicts fair neurologic future outcomes moderate difficulty and may need intervention

adjusting to extrauterine life Explanation: The infant is tolerating the adjustment to extrauterine life; the Apgar scores are within normal limits for appropriate transition. Severe distress and absolute need for resuscitation is an Apgar score of 0 to 3; moderate difficulty is indicated by a score of 4 to 6. An Apgar score of 7 to 10 at 5 minutes indicates a fair neurologic future outcome.

Which newborn neuromuscular system adaptation would the nurse not expect to find? a plantar grasp reflex at 7 months of age a Moro reflex at 3 months of age an extrusion reflex at 9 months of age a positive Babinski sign at 2 months of age

an extrusion reflex at 9 months of age Explanation: An extrusion reflex usually disappears around 4 months of age. A positive Babinski sign 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 neonate born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this neonate? after feedings every 8 hours only if the neonate is jittery before feedings

before feedings Explanation: To screen for hypoglycemia, a glucose level is obtained prior to the first feeding and then prior to feedings for 24 to 48 hours. Neonates are screened even in the absence of symptoms; this is done before feedings to obtain a preprandial measure.

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? Apgar score heart rate temperature blood sugar

blood sugar Explanation: 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? blue or purplish splotches on buttocks bright red, raised bumpy area noted above the right eye fine red rash noted over the chest and back small pink or red patches on the newborn's eyelids and back of the neck

bright red, raised bumpy area noted above the right eye Explanation: 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 (congenital dermal melanocytosis (slate gray nevi) 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 within a few days.

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? an allergic reaction to the soap used for the first bath concentration of immature blood vessels bruising from the birth process an immature autoregulation of blood flow

concentration of immature blood vessels Explanation: 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.

A nurse is teaching new parents how to bathe their newborn once they bring the baby home. Place the body areas listed below in the order that the parents clean the newborn's body. Use all options. 1 diaper area 2 hair 3 eyes 4 face 5 extremities

eyes face hair extremities diaper area Explanation: The parents should wash the newborn, progressing from the cleanest to the dirtiest areas: eyes, rest of face, hair, extremities, trunk, and back. The diaper area is washed last.

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: congenital dermal melanocytosis (slate gray nevi). stork bites. erythema toxic. harlequin sign.

harlequin sign. Explanation: 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. Congenital dermal melanocytosis (slate gray nevi, previously known as 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? vision genetic-linked hearing skeletal malformations

hearing Explanation: 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 Apgar score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, breaths per minute, irritability, tone, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, respiratory effort, temperature, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color Explanation: 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 evaluated by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

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? "Your newborn should finish a bottle in less than 15 minutes." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." Explanation: 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.

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse? "Keep your newborn at home and do not allow visitors for the first month." "Be sure to keep the newborn's umbilical cord stump clean and dry." "Always wash your hands before you pick up or provide care to your newborn." "Be sure to keep all scheduled doctor appointments for vaccinations."

"Always wash your hands before you pick up or provide care to your newborn." Explanation: Handwashing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Vaccinations reduce the risk of infections but good handwashing is priority. Keeping the umbilical cord dry and clean helps prevent an infection at the site. It is not appropriate to restrict visitors who are healthy.

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "Physiologic jaundice usually begins in the first week after birth." "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Explanation: Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? "I can use talc powders to prevent diaper rash." " I will change my baby's diapers frequently." "It is not necessary to give my baby a bath daily." "I will give sponge baths until the umbilical cord falls off."

"I can use talc powders to prevent diaper rash." Explanation: Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is a sign of a group B streptococcus skin infection. " "It is a self-limiting virus that does not require treatment." "It is an indication that the woman has mistreated her newborn." "It is a normal skin finding in a newborn."

"It is a normal skin finding in a newborn." Explanation: This most likely is erythema toxicum, also known as newborn rash, and is a common finding that will gradually disappear and not need any treatment. This is often mistaken for staphylococcal pustules. This is not a sign of mistreatment by the woman, nor is it caused by a virus or group B streptococcal (GBS) infection.

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." This vitamin substitutes for vitamin C for newborns to strengthen their immune systems." "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins."

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." Explanation: Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, does not help prevent ophthalmia neonatorum, or strengthen the immune system.

The primipara 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." "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the tonic neck reflex. It signifies handedness."

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." Explanation: 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 nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? "The teeth will fall out within the first month, so don't worry about them." "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." "The teeth will fall out when the newborn's baby teeth come in so this is a blessing."

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." Explanation: Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? "He has normal male genitalia." "The opening of his urethra in located on the under surface of the tip of the penis." "His testicles have not descended into the scrotal sac." "He has fluid in the scrotal sac."

"The opening of his urethra in located on the under surface of the tip of the penis." Explanation: The term "hypospadias" refers to the urinary meatus (external opening of the urethra) being abnormally located on the ventral (under) surface of the glans (the rounded head or tip of the penis). There are no special terms to indicate normal genitalia. Cryptorchidism refers to undescended testes. Hydrocele refers to the collection of fluid in the scrotal sac.

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "We will fold down the front of her diaper under the umbilical cord until it falls off." "We should clean the skin with soap and water after each bowel movement." "It is best practice to change the diaper every 2 to 4 hours, even during the night."

"We will fold down the front of her diaper under the umbilical cord until it falls off." Explanation: In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective? "We will vigorously rub our baby's back as we play some music." "We will hold feedings until our baby stops crying." "We will place our baby on the belly on a blanket on the floor." "We will turn the mobile on that's hanging on our baby's crib."

"We will turn the mobile on that's hanging on our baby's crib." Explanation: 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 or play calming music or white noise. Swaddling the newborn rather than placing the infant on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll swaddle him snuggly to make him feel secure." "We'll lightly rub his back as we talk to him softly." "We'll hold off on feeding him for a while because he might be too full." "We'll turn on the mobile that's hanging above his head in his crib."

"We'll hold off on feeding him for a while because he might be too full." Explanation: Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. 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.

Assessment of a newborn reveals microcephaly. The nurse develops a teaching plan for the parents about the need for follow-up care based on the understanding that the newborn is at risk for developing which complication(s)? Select all that apply. hydrocephalus achondroplasia cerebral palsy epilepsy hearing disorders

- epilepsy - cerebral palsy - hearing disorders Explanation: Infants with microcephaly are also noted to have additional complications such as epilepsy, cerebral palsy, intellectual disability, and ophthalmologic and hearing disorders. Hydrocephalus and achondroplasia are more commonly seen with macrocephaly.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply. Skin is less susceptible to the sun. Sweat glands are fully functioning at birth. It is thinner and more fragile than an adult's The epidermis is thicker than in adults. Substances are easily absorbed.

- it is thinner and more fragile than an adult's - substances are easily absorbed Explanation: An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.

A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply. arm recoil lanugo posture square window breast tissue

- lanugo - breast tissue Explanation: When assessing physical maturity for a newborn's gestational age assessment, the nurse would assess lanugo and breast tissue. Posture, arm recoil, and square window are components of the neuromuscular maturity assessment.

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. Ensure the newborn's warmth. Observe respiratory status frequently. Provide warm water to drink. Massage the newborn's back. Provide oxygen supplementation.

- provide O2 supplementation - ensure the newborn's warmth - observe respiratory status frequently Explanation: 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.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Identification bands Suction equipment Warmer bed Ophthalmoscope Glucose water

- warmer bed - suction equipment - identification bands Explanation: In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number. ______________

24 Explanation: Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml.

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? When the infant is 48 hours old 24 hours after the newborn's first protein feeding Just before discharge home 36 hours before the infant is discharged home with its parents

24 hours after the newborn's first protein feeding Explanation: 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. Reference:

A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term? 2,200 grams 3,500 grams 1,800 grams 1,200 grams

3,500 grams Explanation: Typically, the term newborn weighs 2,500 to 4,000 g. Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation. A newborn weighing less than 1,500 grams is considered very-low-birth-weight. A newborn weighing 1,800 grams or 2,200 grams would be considered low-birth-weight.

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor? A middle-age woman who lives in another town A teenager who is an honor student at school A clean cut male between the age of 20 and 40 A female in her mid-20s who appears pregnant

A female in her mid-20s who appears pregnant Explanation: Typical abductors are women age 12 to 50 who appear pregnant or are overweight. They are usually married or cohabiting with a companion. They are also usually familiar with the area or live there. Often they will dress as health care personnel such as a nurse or nursing assistant. Men are not typically abductors nor are honor students.