PN108 PrepU Chapter 13(Really 17)

A newborn has physiologic jaundice. The parents ask why the baby has a yellowish skin color. The most appropriate nursing response is which of the following?

"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.

"I understand your concern because as many as 50% of babies can develop jaundice."

The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?

The rooting reflex was tested incorrectly.

What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

a good time to initiate breastfeeding.

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

a respiratory rate of 15 breaths per minute with nasal flaring

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement

What is the best way for the nurse to assess the newborn's heartbeat?

auscultating the apical pulse for 60 seconds

Which is not a cause of jaundice in the newborn?

bilirubin hyperexcretion

When describing the neurologic development of a newborn to the parents, the nurse would explain that the development occurs in which fashion?

center to outside

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

A nurse is conducting a refresher in-service program for a group of neonatal nurses. After teaching the group about hepatic system adaptations after birth, the nurse determines that the teaching was successful when the group identifies which process as reflective of the change of bilirubin from a fat-soluble product to a water-soluble product?

conjugation

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection

A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn?

convection and evaporation

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

evaporation

A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth?

hearing

What are the functions of kangaroo care? Select all that apply.

helps the parents bond with their neonate keeps the neonate warm is skin-to-skin contact

At birth, changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close?

higher oxygen content of the circulating blood

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

limited voluntary muscle activity

The nurse uses a radiant warmer to transport a newborn to reduce heat loss via which mechanism?

radiation

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

respiratory and cardiovascular

All the options are signs of respiratory distress in the newborn except:

respiratory rate >50 breaths/minute.

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

sternal retractions

What is the primary goal of nursing care immediately after birth?

to maintain the safety of the neonate from intrauterine to extrauterine life

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because:

vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth

You are a graduate LVN/LPN seeing your first cesarean delivery. An infant girl is born and as the nurse assesses the infant she asks you what you would carefully assess in this infant. You respond "Respiratory status." The assessing nurse asks you "Why?" What would be your best response?

"There is more fluid is present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

"This is meconium stool and is normal for a newborn."

You are the senior LVN/LPN in the newborn nursery and you are orienting a new graduate LVN/LPN. One of the subjects you want to cover today is hepatic adaptation of the normal newborn. What would you know to talk about?

AquaMEPHYTON

A normal, term newborn with a head circumference of 35 would be expected to have a chest circumference of

33

A hypoglycemic newborn will have a blood glucose reading of what value on heel stick?

45 mg/dL

The nurse is assessing a newborn at 1 minute of life for an APGAR score. The newborn's heart rate is 125, the cry is lusty, the extremities are well flexed, the newborn coughs when a catheter is placed in the nose to remove secretions, and acrocyanosis is present. The nurse gives an APGAR score of ___ for this newborn.

9

In which newborn should the nurse suspect hypoglycemia?

A jittery, irritable newborn with a high-pitched cry

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11.

Place the items regarding changes in fetal circulation at birth in which they occur. All options must be used.

Birth occurs. Pulmonary vascular resistance decreases. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes.

Neonatal hypoglycemia is a risk of newborns with diabetic mothers. What laboratory value would be classified as neonatal hypoglycemia?

Blood glucose of 50 mg/dL

Which statements about brown fat are true?

Brown fat makes up 2% to 6% of a term newborn's body weight. Brown fat is brown and rich in blood vessels and nerve endings. The newborn keeps himself warm by oxidizing brown fat in response to exposure to the cold. Only newborns have brown fat. The most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals.

You are called into the room of one of your clients where the grandparents are visiting with the new parents. The grandmother is visibly upset. She says "Just look at my grandson! His head is all soft here and it shouldn't be. The doctor injured him when he was born and now he will be retarded." You assess the newborn and find an area of swelling about the size of a half-dollar on the scalp. What is this swelling called?

Caput succedaneum

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

Cephalhematoma

You are assessing a newborn girl, four hours old, weighing 9 lbs. 2 oz. While doing the initial assessment the RN mentioned that the mothers' history showed her to be morbidly obese. You would know to observe this infant frequently for signs/symptoms of hypoglycemia. What would be early signs of hypoglycemia in this newborn?

Jitteriness and irritability

When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?

Keeping it dry

In a term newborn, you would expect to find which of the following patterns of sole creases?

Creases on three-fourths of the foot

A nurse is caring for a 3-hour-old newborn boy. The nurse makes the initial assessment and finds the following: respiratory rate 30 bpm, BP 60/40 mm/Hg, heart rate 155 bpm, axillary temperature 98.2° F (36.8° C). The nurse assesses that the newborn is in a state of quiet alert. What should the nurse do?

Document the data.

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly.

You have just received a newborm male into the nursery with the report that he has a hypospadias. What does this mean?

His urinary meatus in located on the under surface of the glans

A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta?

IgG

Which statement is false regarding newborn behavioral patterns?

In the first few hours after birth newborns do not typically demonstrate a response to visual stimuli.

Which of the following would lead you to suspect that a newborn has developmental hip dysplasia?

Inability of the right hip to abduct

Which of the following is true of APGAR scoring? Select all that apply.

It is done at 1 and 5 minutes after birth. The baby is considered vigorous if the 5-minute score is above 7. The APGAR score is an immediate assessment of newborn cardiopulmonary adaptation.

You are assisting with the admission of a newborn boy to the nursery. The mother's history states that she is of Hispanic descent. You note what appears to be bruising on the left upper outer thigh. How would you document this?

Mongolian spot noted on left upper outer thigh

The nurse is assessing a 1-day-old newborn and notices a small amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse?

Notify the charge nurse, because this finding represents a possible complication, and document the finding

Within 3 days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest. The baby is lethargic and has to be woken to feed. The nurse is aware that the most likely condition that the baby is experiencing is:

Physiologic jaundice.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

You inspect a male newborn's genitalia. Which of the following would be inappropriate to include in your assessment?

Retracting the foreskin over the glans to assess for secretions

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?

Taking no action because these are normal findings in a newborn

Which of the following is true regarding the newborn's fontanelles?

The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.